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A  MONOGRAPH 

=  ON  ===== 


The 

Epidemic  oi  Poliomyelitis 

(Infantile  Paralysis) 


IN  NEW  YORK  CITY  IN  1916 

Based  on  the  Official  Reports  of  the  Bureaus  of  the 
Department  of  Health 


PUBLISHED  UNDER  THE  DIRECTION  OF  THE 

DEPARTMENT  OF  HEALTH  OF 

NEW  YORK  CITY 

1917 


Columbia  ^mbetjfiittp  a.op.l 

QlnUpgp  of  piyaatrmns  anJi  ^urgponis 


A  MONOGRAPH 

^=^=   ON  ===== 


The 

Epidemic  of  Poliomyelitis 

(Infantile  Paralysis) 

IN  NEW  YORK  CITY  IN  1916 

Based  on  the  Official  Reports  of  the  Bureaus  of  the 
Department  of  Health 


PUBLISHED  UNDER  THE  DIRECTION  OF  THE 

DEPARTMENT  OF  HEALTH  OF 

NEW  YORK  CITY 

1917 


i     8     8      S.    8     §      8     8     S     8  ,1     »     3     3 8 


\l 


BOARD   OF   HEALTH. 


Haven  Emerson,  M.  D., 
Commissioner  of  Health  and  President  of  the  Board. 

Arthur  Woods, 
Police  Commissioner. 

L.  E.  CoFER,  M.  D., 
Health  Officer  Port  of  New  York. 


TABLE   OF    CONTENTS. 

PAGE 

Introduction    9 

Chapter  I.  Historical   11 

Chapter  II.  Etiolog}- 82 

Chapter  III.  Epidemiology'  93 

Chapter  I\',  Epidemiology,   continued 102 

Chapter  V,  Insects  as  Carriers  of  Infection 136 

Chapter  Yl,  Poliomyelitis  in  Xew  York  State  in  1916 179 

Chapter  \'II,  Patholog}- 188 

Chapter  A'lII,  Symptomatology' ■ .  .  .  196 

Chapter  IX,  Diagnosis  and  Ditt'erential  Diagnosis 201 

Chapter  X,   Prognosis    241 

Chapter  XI.  Record  of  Treatment  Employed 244 

Chapter  XII,  A  Discussion  of  Treatment 264 

Chapter  XIII.  Prophylaxis  290 

Appendix    293 


INTRODUCTION. 

To: 

His  Honor  the  Mayor, 

The  Board  of  Estimate  and  Apportionment, 

The  People  of  Nezv  York  City. 

This  report  of  the  poliomyeHtis  epidemic  is  submitted  as  the  record 
of  an  event  of  importance  to  the  science  of  medicine  and  touching  closely  the 
life  and  happiness  of  individuals  of  this  community. 

Our  present  ignorance  of  such  facts  as  will  permit  of  a  control  of  this 
epidemic  disease  imposes  a  special  duty  to  record  all  data  which  may  con- 
ceivably be  of  value  or  prove  of  service  in  the  further  study  and  solution 
of  the  many  questions  which  must  be  answered  before  we  can  give 
assurance  that  a  repetition  of  a  similar  epidemic  can- be  prevented. 

The  data  are  presented  so  far  as  our  present  understanding  permits 
in  a  way  to  render  possible  the  widest  use  of  the  observations  of  the 
officers  of  the  Department  of  Health  by  those  engaged  in  the  study,  teaching 
and  practice  of  preventive  medicine. 

It  is  expected  that  the  intelligent  lay  reader,  as  well  as  the  large  group 
of  professional  workers  in  medicine  and  associated  sciences  will  find  herein 
a  fund  of  interesting  infonnation  which  may  prepare  them  to  appreciate 
more  clearly  the  possibihties  and  limitations  under  which  the  officers  of 
Federal,  State  or  Municipal  health  organizations  must  apply  the  accepted 
facts  of  science  in  the  administration  of  the  pubHc  health  laws  on  behalf  of 
the  community. 

Beginning  with  an  historical  sketch  of  the  disease  and  proceeding  with 
the  record  of  the  epidemic  in  this  City,  with  a  reference  to  the  extent  of 
its  spread  elsewhere  in  the  United  States,  the  report  will  deal  with  every 
phase  of  the  disease  as  seen  by  the  Department  of  Health,  in  co-operation 
with  other  Departments  of  City,  State  and  Federal  Government,  and  with 
many  official  and  unofficial  advisory  groups  and  organizations. 

No  such  report  can  be  the  production  of  one  mind,  and  I  wish  here 
and  now  to  express  with  all  sincerity  my  respect  and  admiration  for  the 
universal  co-operation  of  the  many  loyal  public  servants  in  the  Department 
of  Health  who  have  made  this  publication  possible. 

At  this  time  and  place,  it  is  peculiarly  fitting  to  express  and  record 
the  appreciation  feh  by  the  Board  of  Health  for  the  admirable  skill  and 
spirit  shown  by  the  officers  of  the  United  States  Public  Health  Service, 
who  were  assigned  to  undertake  epidemiological  studies  of  the  disease  in 


10 

and  about  New  York  City,  and  to  assist  in  such  phases  of  the  administrative 
supervision  of  the  disease  as  affected  interstate  quarantine. 

The  Department  of  Heahh  of  the  City  received  many  benefits  from  the 
cordial  and  effective  co-operation  which  the  State  Department  of  Heahh 
took  pains  to  offer  and  exhibit  on  all  suitable  occasions,  and  there  were 
instances  where  the  officers  of  the  City  were  able  to  reciprocate  in  kind 
for  the  benefit  of  the- citizens  of  State  and  City,  whose  interests  would 
often  have  been  jeopardized  if  there  had  been  anything  less  than  sympathetic 
action  by  the  respective  departments. 

Respectfully  submitted  by 

Haven  Emerson,  M.  D., 

Commissioner  of  Health. 


CHAPTER    I. 
Historical, 

Poliomyelitis  has  been  recorded  in  the  United  States  as  among  the  rarer 
diseases  of  the  central  nervous  system  since  it  was  first  described  by  Heine 
in  1840.  In  1874  it  was  a  disease  of  such  rare  occurrence  or  so  seldom 
recognized  as  a  distinct  clinical  entity,  that  the  leading  consulting  physicians 
of  the  largest  cities  in  this  country  and  abroad  had  not,  in  their  whole  pro- 
fessional careers,  seen  more  than  a  handful  of  cases.  The  knowledge  of 
the  pathology  of  the  disease  at  that  time  was  based  on  a  smaller  number 
of  autopsies  recorded  in  the  whole  medical  literature  than  were  performed  at 
one  of  the  Department  hospitals  during  the  past  summer.  The  average 
number  of  deaths  from  poliomyelitis  in  any  one  of  ten  weeks  during  July, 
August  and  September,  1916,  exceeded  the  deaths  from  this  disease  reported 
in  the  past  five  years  in  New  York  City.  In  fact,  the  deaths  from  this 
disease  were  of  such  rare  occurrence  up  to  the  year  1912,  except  during  the 
epidemic  of  1907,  that  they  were  not  even  separated  from  the  general  group 
of  "other  diseases  of  the  nervous  system."  In  the  years  1912-1915  there 
were  respectively  70,  54,  34  and  13  deaths  from  the  disease  and  in  1916  up 
to  June  1,  there  were  only  6  deaths,  while  the  average  weekly  number  of 
deaths  from  July  1  to  September  9,  1916,  was  209. 

Since  the  early  years  of  this  century  there  has  been  an  increasing  general 
area  of  distribution  in  this  country  and  a  growing  incidence  of  the  disease. 
Over  5,000  deaths  from  poliomyelitis  are  recorded  by  the  United  States 
Census  Bureau,  as  having  occurred  in  the  registration  area*  in  the  quin- 
quenium  1910  to  1914.  A  conservative  estimate  would  place  the  probable 
number  of  cases  during  these  five  years  in  this  area  as  30,000. 

Over  27,000  cases  and  6,000  deaths  from  poliomyelitis  occurred  in  the 
registration  area  from  June  to  November,  1916.  During  the  past  summer 
there  were  other  distilict  foci  of  infection  evidently  independent  in  their 
origin  and  not,  so  far  as  could  be  learned,  traceable  to  each  other  or  to 
the  City  of  New  York.  These  were  roughly  the  State  of  Minnesota  and 
the  South  Atlantic  States,  each  of  which  areas  was  responsible  for  a  con- 
siderable number  of  cases  pretty  widely  distributed. 

Although  foci  of  infection  in  many  localities  in  the  States  adjacent  to 
New  York  City  and  State,  closely  bound  to  it  by  social,  business  and  trans- 
portation connections,  apparently  had  their  own  local  origins,  the  great 
rr-^iority  of  cases  in  the  metropolitan  area  extending  into  New  Jersey,  Con- 

*The  Registration  Area  of  the  U.  S.  Census  embraces  those  states  and  cities 
whose  vital  statistics  are  regarded  as  sufficiently  complete  and  accurate  to  warrant 
tabulation  by  the  Census  Office.  At  the  present  time  the  area  includes  26  states  and 
36  cities  outside  of  these  states.     In  1916  this  area  had  a  population  of  71,621,632. 


CHAPTER    I. 
Historical. 

Poliomyelitis  has  been  recorded  in  the  United  States  as  among  the  rarer 
diseases  of  the  central  nervous  system  since  it  was  first  described  by  Heine 
in  1840.  In  1874  it  was  a  disease  of  such  rare  occurrence  or  so  seldom 
recognized  as  a  distinct  clinical  entity,  that  the  leading  consulting  physicians 
of  the  largest  cities  in  this  country  and  abroad  had  not,  in  their  whole  pro- 
fessional careers,  seen  more  than  a  handful  of  cases.  The  knowledge  of 
the  pathology  of  the  disease  at  that  time  was  based  on  a  smaller  number 
of  autopsies  recorded  in  the  whole  medical  literature  than  were  performed  at 
one  of  the  Department  hospitals  during  the  past  summer.  The  average 
number  of  deaths  from  poliomyelitis  in  any  one  of  ten  weeks  during  July, 
August  and  September,  1916,  exceeded  the  deaths  from  this  disease  reported 
in  the  past  five  years  in  New  York  City.  In  fact,  the  deaths  from  this 
disease  were  of  such  rare  occurrence  up  to  the  year  1912,  except  during  the 
epidemic  of  1907,  that  they  were  not  even  separated  from  the  general  group 
of  "other  diseases  of  the  nervous  system."  In  the  years  1912-1915  there 
were  respectively  70,  54,  34  and  13  deaths  from  the  disease  and  in  1916  up 
to  June  1,  there  were  only  6  deaths,  while  the  average  weekly  number  of 
deaths  from  July  1  to  September  9,  1916,  was  209. 

Since  the  early  years  of  this  century  there  has  been  an  increasing  general 
area  of  distribution  in  this  country  and  a  growing  incidence  of  the  disease. 
Over  5,000  deaths  from  poliomyelitis  are  recorded  by  the  United  States 
Census  Bureau,  as  having  occurred  in  the  registration  area*  in  the  quin- 
quenium  1910  to  1914.  A  conservative  estimate  would  place  the  probable 
number  of  cases  during  these  live  years  in  this  area  as  30,000. 

Over  27,000  cases  and  6,000  deaths  from  poliomyelitis  occurred  in  the 
registration  area  from  June  to  November,  1916.  During  the  past  summer 
there  were  other  distinct  foci  of  infection  evidently  independent  in  their 
origin  and  not,  so  far  as  could  be  learned,  traceable  to  each  other  or  to 
the  City  of  New  York.  These  were  roughly  the  State  of  Minnesota  and 
the  South  Atlantic  States,  each  of  which  areas  was  responsible  for  a  con- 
siderable number  of  cases  pretty  widely  distributed. 

Although  foci  of  infection  in  many  localities  in  the  States  adjacent  to 
New  York  City  and  State,  closely  bound  to  it  by  social,  business  and  trans- 
portation connections,  apparently  had  their  own  local  origins,  the  great 
n-'iority  of  cases  in  the  metropolitan  area  extending  into  New  Jersey,  Con- 

*The  Registration  Area  of  the  U.  S.  Census  embraces  those  states  and  cities 
whose  vital  statistics  are  regarded  as  sufificiently  complete  and  accurate  to  warrant 
tabulation  by  the  Census  Oflfice.  At  the  present  time  the  area  includes  26  states  and 
36  cities  outside  of  these  states.     In  1916  this  area  had  a  population  of  71,621,632. 


13 


from  which  borough  no  cases  had  been  reported  up  to  this  time  in  1916  and 
none  in  June  from  the  other  boroughs.  The  six  cases  were  reported  as 
follows : 


Date 
Reported. 


June  6th. 
June  6th. 
June  8th. 
June  8th. 
June  8th. 
June  8th. 


Name. 

John    Pamaris 

Armanda  Schuccjio 
William  Cortell  . . . . 

John  Lessa   

Tony  Piclo   

Mitchell  Alvin  


Age.  Address. 

10  months   53  Garfield  place. 

2  years  8  months  5014  Seventh  avenue. 

8  years  630  Forty-fifth  street. 

20  months   282  First  street. 

1  year  251  Third  avenue. 

iy2  years 78  Utica  avenue. 


Only  five  cases  in  the  entire  city  had  been  reported  to  the  Department 
of  Health  in  May,  and  yet  when  we  assign  the  cases,  which  were  reported 
at  later  dates  (discovered  by  the  house  to  house  visits  of  doctors  and 
nurses  of  the  Department  in  the  section  of  Brooklyn  first  invaded,  a  thickly 
populated  Italian  section,  bounded  by  Fourth  avenue,  Nevins,  Carroll  and 
Union  streets),  to  the  date  when  the  first  symptoms  of  sickness  were  ob- 
served, i.  e.,  to  the  date  of  onset  of  the  disease  in  each  case,  wei  find  that 
in  the  month  of  May,  29  cases  of  poliomyelitis  had  their  origin  and  were 
doubtless  capable  of  spreading  the  disease  to  or  through  those  with  whom 
they  came  in  contact.  . 

It  must  be  remembered  that  none  of  these  29  cases,  in  which  the  onset 
occurred  before  Jiine  6th  were  known  to  the  officers  of  the  Health  Depart- 
ment, until  the  house  to  house  search,  after  June  6th  disclosed  their  where- 
abouts, and  it  was  only  the  report  of  the  6  cases  from  Brooklyn,  2  on  June 
6th  and  4  on  June  8th,  which  served  as  a  warning  of  an  impending  epidemic. 

Further,  it  is  well  to  bear  in  mind  that  although  at  the  beginning,  and 
throughout  the  epidemic,  Brooklyn  supplied  the  largest  number  of  cases, 
the  unreported  cases  which  had  their  onset  before  June  6th  were  distributed 
throughout  the  five  boroughs  : 

3  in  May  in  Manhattan. 
1  on  June  2d  in  The  Bronx. 
22  in  May  in  Brooklyn. 
3  in  May  in  Queens. 
1  in  May  in  Richmond. 

On  June  8th,  when  the  homes  of  the  6  reported  cases  were  found  to  be 
in  a  fairly  circumscribed  area,  and  when  a  notice  was  received  from  the 
research  force  of  the  Department  laboratory  that  an  unusual  number  of 
requests  had,  within  the  past  few  days  been  received,  for  positive  diagnosis 
in  cases  of  suspected  poliomyelitis,  orders  were  given  to  make  an  immediate 
and  special  investigation,  by  inquiry  of  physicians  practicing  in  the  area 
affected,  and  by  instituting  a  house  to  house  canvass  for  unreported  and 
unrecognized  cases.  That  there  was  not  an  earlier  recognition  of  the 
approaching  epidemic  and  a  study  of  the  disease  from  the  epidemiological 


14 

standpoint,  was  due  solely  to  the  fact  that  none  of  the  cases  which  occurred 
in  May  and  before  the  6th  of  June  were  reported  to  the  Department  of 
Health.  It  is  not  to  be  inferred,  that  this  failure  was  due  wholly  to  the 
not  uncommon  delay  in  reporting  cases  of  notifiable  disease  by  practicing 
physicians,  but  is  to  be  attributed  largely  to  the  fact  that  this  disease  is 
not  always  sufficiently  severe  in  its  early  symptoms  to  demand  immediate 
medical  attention,  according  to  the  idea  of  many  parents,  and  further  to 
the  equally  important  fact  that  only  a  complete  physical  examination  with 
special  attention  to  the  response  of  various  tests  of  muscular  reflexes  will 
elicit  the  evidences  of  paralysis  in  many  of  the  mild  cases. 

Only  a  thoroughly  alert  public  and  a  forewarned  profession  could 
have  prevented  the  delay  in  official  knowledge  of  the  threatening  epidemic. 
That  energetic  measures  were  taken  as  soon  as  six  verified  cases  of  the 
disease  were  reported  on  June  6th  and  8th,  is  a  sufficient  reply  to  any 
lingering  suspicions  that  the  Department  of  Health  awaited  the  actual 
presence  of  a  calamity  before  taking  measures  of  protection. 

On  June  15th,  in  addition  to  a  number  of  cases  discovered  by  visits 
of  medical  inspectors  and  nurses  throughout  the  now  obviously  infected  area 
of  Brooklyn,  several  cases  of  recent  paralysis  were  noted  among  the 
infants  attending  the  Baby  Health  Station  at  184  Fourth  avenue,  Brooklyn. 
The  mothers  of  these  children,  all  unaware  of  the  existence  of  the  disease 
or  its  communicable  character,  brought  their  babies  to  the  doctors,  com- 
plaining that  the  child  could  not  hold  the  bottle  or  that  the  leg  seemed 
limp  for  the  past  few  days,  and  there  had  been  a  little  loss  of  appetite 
and  some  restlessness. 

Official  Notice  of  Unusual  Prevalence  of  Acute  Poliomyelitis  in 

Epidemic  Form. 

The  first  official  announcement  of  the  existence  of  an  unusual  num- 
ber of  cases  of  poliomyelitis  in  New  York  City  (in  the  Borough  of  Brook- 
lyn) was  made  in  a  press  bulletin  issued  Saturday,  June  17th,  and  published 
in  the  newspapers  on  the  following  day.  As  in  the  case  of  all  the  press 
bulletins  issued  by  the  Department  of  Health,  multigraphied  copies  of  this 
bulletin  were  sent  to  all  the  newspapers  in  the  City,  to  the  medical  journals 
and  to  all  the  important  news  bureaus.  This  first  bulletin  called  attention 
to  the  value  of  spinal  fluid  examinations  in  the  diagnosis  of  poliomyelitis 
and  announced  that  lumbar  puncture  and  the  laboratory  examination  of 
spinal  fluid  would  be  made  free  of  charge  by  the  Department  of  Health. 

At  the  same  time  a  letter  was  sent  to  all  the  physicians  in  Brooklyn, 
calling  attention  to  the  existence  of  a  group  of  cases  of  poliomyelitis  in  their 
borough,  and  asking  for  their  co-operation  in  controlling  the  disease. 

Owing  to  the  interest  manifested  by  the  newspapers  in  the  epidemic, 
and  in  order  to  make  certain  that  information  emanating  from  the  Depart- 


15 

merit   of   Health   should   be   accurate,   a   daily   press   bulletin   service   was 
inaugurated. 

At  a  little  later  date  (June  30th),  the  Surgeon  General  of  the  United 
States  Public  Health  Service  was  notified  that  an  epidemic  was  under  way, 
and  the  facts  upon  which  this  belief  was  based  were  given  in  full.  The 
New  York  State  Department  of  Health  and  the  health  officers  of  neighbor- 
ing States,  and  of  a  few  of  the  larger  nearby  communities  were  notified  at 
the  same  time. 

Emergency  Field  Force  Assigned. 

On  June  20th,  seven  additional  nurses,  and  on  June  22nd  a  supple- 
mentary corps  of  medical  inspectors  were  assigned,  the  nurses  to  search  for 
unreported  and  unrecognized  cases  by  an  extension  of  the  house-to-house 
visits,  and  the  medical  inspectors  to  visit  the  numerous  cases  now  reported, 
to  confirm  the  diagnosis  made  by  the  family  physician  and  to  examine 
suspects  reported  through  many  non-professional  channels. 

The  American  Society  for  the  Prevention  of  Cruelty  to  Animals  was 
requested  to  take  immediate  measures  to  collect  all  stray  cats  and  dogs  found 
in  the  infected  localities. 

The  Department  of  Street  Cleaning  began  active  co-operation  to  give  a 
special  clean-up  in  South  Brooklyn  and  to  discontinue  the  use  of  burlap 
bags  in  the  daily  collection  of  rubbish. 

On  June  23rd,  there  were  reported  48  cases,  about  half  among  Italian 
families,  as  compared  with  a  total  of  63  reported  up  to  this  date.  Many  of 
these  were  of  considerable  duration,  their  onsets  having  occurred  even  in 
the  month  of  May,  and  almost  all  of  them  had  either  escaped  recognition 
as  poliomyelitis  by  the  private  physician  or  had  not  been  under  medical 
care.  A  further  evidence  that  many  cases  had  escaped  detection  for  some 
weeks,  and  had  been  exposing  others  to  infection  for  a  considerable  period, 
was  presented  by  a  leading  orthopaedic  surgeon  in  Brooklyn,  to  whose 
dispensary  class  cases  applied  with  already  well  developed  deformities,  fol- 
lowing the  acute  onset  of  paralysis. 

On  June  24th,  in  order  to  give  immediate  reply  to  many  anxious 
inquiries  and  suggestions  as  to  the  part  played  by  schools  in  the  spread  of 
the  disease,  a  press  bulletin  was  issued,  pointing  out  the  facts  that  90  per 
cent,  of  the  cases  were  in  children  under  school  age,  that  the  cases  were 
not  limited  to  any  one  school  district  or  to  children  of  the  same  classroom. 
The  school  term  ended  on  June  30th.  At  the  same  time  there  was  issued  a 
special  bulletin  for  parents,  emphasizing  the  known  facts  which  would 
be  of  service  in  preventing  the  spread  of  the  disease  in  homes.  The 
presence  of  the  virus  in  the  discharges  from  nose  and  throat,  and  bowels 
of  infected  individuals,  the  probability  that  atypical  and  non-paralytic  cases 
were  as  dangerous  and  as  numerous  as  the  paralytic  cases,  and  that  little 
value  or  protection  could  be  expected  from  the  use  of  so-called  antiseptic 
gargles  and  nose-sprays,  were  explained. 


16  / 

Co-operation  of  Newspapers. 

The  advantages  to  be  expected  from  intelligent  and  alert  self-interest, 
and  the  rapidly  increasing  number  of  cases  reported  day  by  day,  determined 
the  Department  to  take  the  unusual  step  of  publishing  in  the  daily  press  the 
names  and  addresses  of  all  true  cases  reported  in  the  previous  twenty-four 
hours.  This  decision  was  made  after  conference  with  the  Corporation 
Counsel's  office  and  with  the  managing  editors  of  some  of  the  prominent 
newspapers.  The  first  list  was  printed  on  June  28th,  and  this  practice 
was  followed  daily  thereafter  until  September  9th,  after  which  date  the 
Sunday  list  was  omitted  each  week.  On  October  17th  a  weekly  list  was 
substituted,  and  on  November  6th  further  press  publication  of  names  and 
addresses  was  discontinued,  and  thereafter  the  reported  cases  of  polio- 
myelitis were  printed  only  on  the  daily  list  as  issued  for  many  years  past  to 
all  schools,  child  caring  institutions,  etc.  From  the  beginning,  the  interest 
and  co-operation  of  foreign-language  newspapers  were  enlisted  for  publica- 
tion of  daily  lists,  and  all  official  press  bulletins. 

Establishment  of  Quarantine  Regulations. 

On  June  28th  the  Board  of  Health  met  and  passed  resolutions  requir- 
ing eight  weeks'  isolation  instead  of  six  weeks,  and  demanding  immediate 
hospitalization  of  all  patients  for  whom  the  following  requirements  could  not 
be  met : 

(a)  Daily  attendance  of  a  physician. 

(b)  Special  attendant  who  must  observe  quarantine  regulations, 
do  no  cooking,  and  avoid  contact  with  other  children  of  the  house- 
hold. 

(r)   Special  room  for  patient  and  attendant. 

(d)  Screening  of  windows  of  patient's  room. 

(e)  Separate  toilet  for  the  family. 

(/)   P^xclusion  of  food  handlers  from  work. 
(g)   Disinfection  of  bed  linen  of  the  patient  and  renovation  of 
.room  occupied,  after  removal  of  patient. 

The  rapid  accumulation  of  patients  at  Kingston  Avenue  Hospital,  to 
which  all  Brooklyn  cases  were  taken,  made  it  necessary  to  transfer  con- 
valescents to  other  hospitals  of  the  Department,  and  later  to  the  many 
private  hospitals  which  offered  their  facilities  to  the  City.  This  procedure 
of  sending  all  cases  for  immediate  admission  to  a  hospital  in  the  borough 
of  residence  was  carried  out,  with  but  rare  exception,  throughout  the 
epidemic,  the  opening  of  the  new  contagious  disease  hospital  of  the  Depart- 
ment of  Health,  the  Queensboro  Hospital  at  Jamaica,  on  June  29th,  and  the 
offer  of  the  Swinburne  Island  Hospital  and  medical  and  nursing  staff  to  the 
City  by  the  Health  Officer  of  the  Port,  providing  Queens  and  Richmond 
with  excellent  local  isolation  facilities,  the  Boroughs  of  Manhattan  and 
The  Bronx  being  served  by  Willard  Parker  and  Riverside  Hospitals  respec- 


17 

tively.     Patrolmen  of  the  Sanitary  Squad  were  assigned  to  visit  quarantined 
premises  even,-  other  day  and  enforce  the  regulations. 

On  Tune  29th  the  Queensboro  Hospital  was  opened,  thus  giving  imme- 
diate relief  to  the  Kingston  Avenue  Hospital,  already  crowded.  By  using 
the  screened  porches  and  obtaining  accommodations  for  nurses  in  a  neigh- 
boring house  rented  for  this  purpose,  it  was  found  possible  to  accommodate 
as  many  as  112  children  at  a  time,  though  the  normal  capacity  of  the  hospital 
is  80  patients. 

Advisory  Committee  ox  Poliomyelitis. 

On  June  30th,  there  met  for  the  first  of  its  nine  sessions,  an  Advison,- 
Committee  to  the  Department  of  Health.  To  this  Committee  were  sub- 
mitted all  the  important  matters  in  relation  to  the  administrative  and  pro- 
fessional work  of  the  Department  of  Health  in  the  epidemic,  concerning 
which  professional  opinion  was  divided,  or  at  least  not  yet  positively  de- 
clared. Two  members  of  the  Committee  on  Poliomyelitis  of  the  Xew  York 
Neurological  and  the  Pediatric  Section  of  the  Xew  York  Academy  of 
Medicine,  which  studied  the  epidemic  of  1907,  and  prominent  consultants  in 
three  special  branches  of  medicine,  namely  pediatrics,  orthopaedics,  and 
neurolog}',  served  on  this  Committee  throughout  the  summer,  and  all  the 
decisions  reached,  or  new  policies  introduced  by  the  Department  of  Health 
were  submitted  to  this  Committee  for  discussion  and  vote.  Furthermore, 
through  this  Committee,  the  Department  was  able  to  keep  in  touch  with 
the  needs  and  difficulties  of  the  medical  profession  and  to  meet  as  promptly 
as  possible  all  reasonable  complaints,  for  it  must  be  evident  to  the  lay  reader 
that  the  administrative  regulation  of  the  disease  implied  not  only  inter- 
ference with  the  personal  liberty  of  the  members  of  many  households,  but  a 
sacrifice  of  important  professional  opportunities  and  income  by  the  physi- 
cians to  the  poor,  whose  poliomyelitis  patients  were  removed  from  insuf- 
ficiently equipped  homes  to  the  hospitals. 

Immediately  after  the  meeting  for  organization  of  the  Committee,  at 
which  the  hospitalization  and  quarantine  period  already  adopted  by  the 
Department  of  Health  was  endorsed,  two  leaflets  of  information  were 
issued,  one  for  laymen  and  one  for  physicians,  and  posters  and  leaflets 
in  Italian  and  Yiddish  were  prepared.  The  Committee  advised  the  placard- 
ing of  premises  for  poliomyeHtis,  a  practice  previously  confined  to  smallpox, 
scarlet  fever,  diphtheria  and  measles. 

Increase  ix  Field  Force — Educatioxal  Ca:^ipaigx  Started. 

On  July  1st,  ten  additional  inspectors  (physicians)  and  ten  more  nurses 
were  assigned  to  the  special  corps  of  field  agents  to  discover  cases  and  main- 
tain the  observance  of  home  quarantine  regulations.  On  this  date  also  was 
held  the  first  lecture  on  poliomyelitis  for  the  benefit  of  the  practicing  physi- 
cians of  Brooklyn.     Dr.  Simon  Flexner  assisted  the  representative  of  the 


18 

Department  of  Health  in  presenting  to  the  physicians  assembled  at  the 
Polhemus  Clinic  of  the  Long  Island  College  Hospital  the  important  facts 
bearing  upon  the  diagnosis,  transmission  and  prevention  of  the  disease. 
Addresses  and  lectures,  and  lecture-clinics  were  given  all  through  the 
epidemic,  those  which  were  of  special  importance  being  the  great  meeting 
of  the  New  York  Academy  of  Medicine  on  July  13th,  when  the  Aeolian 
Hall  was  filled  to  its  capacity  to  listen  to  a  symposium  upon  various  phases 
of  the  disease,  and  the  system  of  clinics  at  hospitals  inaugurated  on  July 
24th. 

Special  Poliomyelitis  Clinics. 

Inasmuch  as  prompt  diagnosis  by  the  attending  physicians  is  of  para- 
mount importance  in  the  administrative  control  of  infectious  diseases,  and 
because  it  was  realized  that  many  of  the  physicians  in  this  city  probably  had 
not  had  the  opportunity  to  observe  any  considerable  number  of  cases  of 
poliomyelitis  in  the  past,  the  Department  of  Health  decided  to  organize  a 
series  of  bedside  clinics  open  to  practicing  physicians  in  this  city.  Through 
the  co-operation  of  the  attending  physicians,  special  poliomyelitis  clinics 
were  arranged  for  at  the  following  hospitals,  the  clinics  to  be  held  during  the 
week  commencing  July  24th : 

Babies'  Hospital, 

Bellevue  Hospital, 

Kingston  Avenue  Hospital, 

Mt.  Sinai  Hospital, 

Swinburne  Island  (Quarantine  Station), 

Willard  Parker  Hospital. 

Multigraphed  announcements  regarding  these  clinics  were  sent  by  mail 
to  every  physician  in  the  city,  and  a  notice  was  also  published  in  the  Weekly 
Bulletin.  The  clinics  were  so  well  attended  and  so  many  requests  were 
received  for  more  clinics  that  an  additional  course  was  arranged  for, 
beginning  August  14th.  Held  at  the  following  hospitals,  these  clinics  con- 
tinued until  about  October  1. 

Babies'  Hospital,  every  Thursday  at  4  P.  M. 

Bellevue   Hospital,   Ward   32    (Contagious),   every   Monday  at  4 

P.  M. 
Kingston  Avenue  Hospital,  every  Friday  at  4  P.  M. 
Lebanon  Hospital,  every  Tuesday  at  3  :30  P.  M. 
Mt.  Sinai  Hospital,  every  Friday  at  4  P.  M. 
Willard  Parker  Hospital,  every  Wednesday  at  4  P.  M. 

In  order  that  the  clinics  would  give  the  physicians  attending  the  same 
a  fairly  complete  summary  of  the  known  facts  regarding  poliomyelitis,  the 
following  outline  on  the  points  to  be  covered  was  sent  to  each  physician 
holding  a  clinic : 


19 

NOTES  ON  POINTS  TO  BE  COVERED  IN  A  LECTURE-CLINIC  ON  POLIOMYELITIS. 

The  Disease  in  General. 

1.  Nature  of  the  Disease  (emphasize  general  systematic  intoxica- 
tion). 

2.  Where  virus  is  found  (mucous  membrane  of  nose,  throat,  in- 
testines, central  nervous  system,  lymph  nodes). 

3.  How  virus   is  spread    (nose  and  throat — intestinal)    personal 
contact. 

4.  Epidemiology    (emphasize  importance  of  non-paralyzed  cases 
and  normal  "  carriers  "). 

The  Case  or  Cases  in  Particular;  to  be  demonstrated. 

1.  History  of  case. 

2.  General  systematic  intoxication. 

a.  Psychic  state : 

(1)  Stuporous. 

(2)  Hyperexcitable. 

(3)  Alert  and  apprehensive. 

b.  Physical  signs : 

(1)  Fever,  pulse  and  respiration  increased. 

(2)  Lymphadenopathy. 

(3)  Tenderness. 

3.  Central  Nervous  System: 

a.  Reflexes.  ' 

b.  Detection  of  weak  muscle  groups. 

c.  Ataxia  and  equilibrium  disturbances. 

d.  Spinal  region  pain  sign.    Protective  Opisthotonos : 

(1)  Neck. 

(2)  Kernig. 

4.  Laboratory  Aids : 

a.  Blood  count. 

b.  Spinal  fluid. 

c.  Autopsies. 

d.  Animal  inoculation.  ,     , 

5.  Treatment : 

a.  General  Management : 

(1)  Rest. 

(2)  Diet. 

(3)  Pain  control. 

b.  Nursing: 

(1)  Gaining  confidence. 

(2)  Careful  manipulation. 

(3)  Asepsis. 

c.  Special  Procedures : 

(1)  Immune  serum  in  injection. 

(2)  Adrenalin. 

(3)  Artificial  respiration,  etc. 

(4)  Massage  and  passive  motion. 

(5)  Splinting,  etc. 


20 


The  City  and  the  medical  profession  owe  a  special  debt  to  the  volunteers 
who  amid  the  anxious  hours  overfilled  with  hospital  duties  and  private 
practice,  afforded  the  necessary  time  and  thought  to  offer  to  their  fellow 
practitioners  admirable  clinical  instruction,  under  the  most  auspicious  condi- 
tions, for  direct  application  among  the  children  of  the  City. 
Additional  Private  Ambulances  Assigned  to  the  Service  of  the  City. 
On  July  2nd  it  was  found  that  the  Department  ambulances  were  insuffi- 
cient to  remove  all  cases  of  isolation  hospitals  as  rapidly  as  they  were  re- 
ported and  the  diagnosis  was  confirmed.  Delays  of  serious  nature  occurred 
and  as  promptness  of  separation  of  the  sick  from  the  susceptible  was  the 
essence  of  the  plan  now  in  operation,  the  Ambulance  Board  was  requested 
to  loan  additional  ambulances,  which  they  did.  Throughout  the  epidemic 
the  Department  of  Health  had  at  its  service  besides  its  own  nine  ambulances, 
those  loaned  by  twenty-three  other  hospitals,  and  made  available  for  periods 
of  one  to  twenty-four  days  at  a  time.  This  generous  and  timely  aid  was  ot 
a  kind  with  many  other  similar  instances  of  pubHc  spirit  shown  by  the 
hospitals  of  the  City  throughout  the  summer. 

In  addition  to  this  a  prominent  automobile  concern  donated  the  services 
of  a  special  motor  ambulance  throughout  the  epidemic. 

On  this  day  also,  the  superintendents  of  dispensaries  and  institutions 
for  children  were  warned  to  hold  any  suspected  or  recognized  cases  of 
poliomyelitis  on  the  premises  until  the  arrival  of  a  Department  representa- 
tive. 

By  this  time  it  was  evident  that,  even  by  sacrificing  some  of  the  many 
important  routine  duties  of  the  Health  Department  and  devoting  the  entire 
staff  of  the  Department  to  the  control  of  the  epidemic,  the  necessary  means 
of  coping  with  the  situation  would  be  lacking,  and  at  a  special  meeting  of  the 
Board  of  Health,  the  following  memorial  was  prepared,  requesting  the 
Mayor  to  use  his  powers  under  the  Charter,  to  make  available  funds  to  meet 
the  extraordinary  expense  of  the  Department : 

"  Whereas,  The  Board  of  Health  having  taken  and  filed  among 
its  records  what  it  regards  as  sufficient  proof  to  authorize  the  declara- 
tion of  great  and  imminent  peril  to  the  public  health  by  reason  of 
impending  pestilence  arising  from  an  outbreak  of  poliomyelitis  (in- 
fantile paralysis)  throughout  the  City,  pursuant  to  section  1178  of 
the  Greater  New  York  Charter,  the  Board  of  Health  hereby 

"  Resolves,  That  great  and  imminent  peril  exists  to  the  public 
health  of  the  people  of  the  City  of  New  York  by  reason  of  an  out- 
break of  poliomyehtis  (infantile  paralysis)  throughout  the  City  of 
New  York ;  and  further  be  it 

"  Resolved,  That  the  Board  of  Health  does  hereby  order  that 
every  effort  be  made  to  check  and  stamp  out  the  outbreak  of 
poHomyelitis  (infantile  paralysis)  and  does  order  that  the  same  be 
done  by  and  through  its  officers  and  employees  and  those  whom  it 
may  employ  for  such  purpose,  and  does  hereby  cause  such  expendi- 


21 

tures  to  be  made  (beyond  those  duly  estimated  for  and  provided), 
for  the  preservation  of  the  public  health  as  may  be  necessary  and  as 
public  safety  and  health  may  demand.  The  expenditures  aforesaid 
are  hereby  consented  to. 

"  Haven  Emersox, 

"  Commissioner  and  President,  Board  of  Health, 

"  Frank  A.  Lord, 

"■  Second  Deputy  Police  Commissioner. 

"L.   E.   COFER^ 

"  Health  Officer  of  the  Port  of  New  York, 

"  July  5,  1916. 

"  On  the  foregoing  resolution, 

"  I,  John  Purroy  Mitchel,  Mayor  of  The  City  of  New  York, 
do  hereby  declare  that  imminent  peril  to  the  public  health  exists  and 
approve  of  the  foregoing  expenditures. 

"  John  Purroy  Mitchel, 

"  flavor. 
"  July  5,  1916." 

The  report  of  the  Auditor  of  the  Department  will  give,  at  a  glance,  the 
character  of  the  personal  services  and  supplies  found  necessary  and  met 
from  the  emergency  fund  (page  72). 

Public  Assemblages  Restricted  to  Adults. 

On  July  5th  all  theatres  and  moving  picture  theatres  were  closed  to 
children  under  sixteen,  and  on  July  8th,  the  streets  known  as  play  blocks, 
provided  for  the  sake  of  giving  safe  play  space  for  the  children  in  many 
parts  of  town  under  the  auspices  of  the  Police  Department  were  abandoned. 
Street  carnivals,  parades,  public  picnics  and  excursions  were  forbidden. 
These  restrictions  were  removed  from  theatres,  except  for  children  under 
12,  on  September  9th,  and  on  September  25th  restrictions  of  all  kinds  apply- 
ing to  places  of  public  assembly  were  removed. 

Restrictions  Enforced  in  Institutions  for  Children. 

On  this  date  also,  in  order  to  prevent  the  introduction  of  poliomyelitis 
into  the  institutions  for  children,  the  following  precautions  were  put  into 
effect : 

1.  Repeated  sanitary  inspections  made  of  premises  and  recom- 
mendations offered  in  regard  to  proper  cleaning  of  buildings. 

2.  All  windows  and  doors  of  children's  dormitories  and  dining 
rooms  were  screened. 

3.  An  eft"ort  was  made  to  kill  all  flies  and  vermin,  such  as  bed- 
bugs and  roaches. 

4.  Garbage  and  refuse  were  immediately  destroyed  on  the 
grounds. 

5.  The  milk  supply  and  other  food  used  were  examined  at 
frequent  intervals,  and  any  evidence  of  deterioration  was  immediately 


22 

called  to  the  attention  of  the  persons  in  charge.    Light,  easily  digested 
food  advised. 

6.  The  daily  brushing  of  the  teeth  and  washing  the  mouth  with 
some  form  of  mild  antiseptic  solution  was  encouraged. 

7.  Individual  towels  and  soap  were  given  to  each  child. 

8.  The  children  were  bathed  frequently  and  the  clothing  was 
kept  scrupulously  clean.  Each  child  was  given  a  clean  piece  of  white 
muslin  every  day  to  be  used  as  a  handkerchief. 

9.  An  examination  by  the  nurse  was  made  of  each  child  every 
morning,  and  whenever  any  fever  was  found  the  institution  physician 
was  immediately  called  and  he  in  turn  notified  the  institution  inspector 
of  the  Health  Department,  if  necessary.  If  any  evidence  of  a  con- 
tagious disease  was  discovered,  the  child  was  immediately  placed  in 
quarantine.    No  child  was  allowed  to  remain  in  the  dormitory  if  sick. 

At  the  beginning  of  the  epidemic  of  poliomyelitis,  the  Department  of 
Charities  and  the  various  Children's  Courts  of  the  City  were  communicated 
with  and  were  requested  to  notify  the  Health  Department  when  a  child  was 
committed  to  an  institution.  A  daily  report  was  received,  giving  the  name 
of  the  child,  address  whence  it  came  and  the  name  of  the  institution  to 
which  it  was  committed.  The  child  was  examined  by  an  inspector  of  the 
Department  of  Health  on  the  day  after  it  was  assigned  to  the  institution 
and  again  after  the  expiration  of  the  two  weeks'  quarantine,  before  being 
allowed  to  go  to  the  dormitory  of  the  institution  proper. 

Regulations  Observed  by  the  Institutions^  at  the  Direction  of  the 

Department  of  Health, 

1.  Every  child  must  be  examined  by  an  inspector  of  the  Divi- 
sion of  Institution  Inspection  on  the  day  following  its  arrival  at  the 
institution  and  again  after  the  expiration  of  two  weeks,  before  being 
admitted  to  contact  with  the  other  inmates. 

2.  Visiting  children  by  parents,  guardians  or  relatives  is  tempo- 
rarily prohibited. 

3.  Food,  articles  of  clothing  or  toys  must  not  be  brought  to  the 
children  by  parents  or  friends  during  the  present  epidemic  of 
poliomyelitis. 

4.  Permission  to  children  must  not  be  given  to  visit  relatives  or 
friends  in  the  city  and  return  to  the  institution. 

5.  Children  must  not  be  permitted  to  attend  public  gatherings. 

6.  Unnecessary  grouping  of  the  children  of  one  dormitory  with 
those  of  another  is  to  be  avoided. 

7.  Every  child  showing  evidence  of  being  ill  must  be  removed 
immediately  to  the  institution  hospital  and  not  be  allowed  to  remain 
in  the  dormitory.  If  the  physician  suspects  any  contagious  disease, 
he  is  to  notify  the  Health  Department  at  once,  and  an  inspector 
trained  in  the  diagnosis  of  infectious  diseases,  will  be  sent  to  examine 
the  patient. 

8.  Employees  living  outside  of  the  institution  must  change  their 
clothing  before  mingHng  with  the  children. 

9.  Every  child  going  to  an  institution  from  its  residence  in  the 
city  for  a  temporary  stay,  must  have  a  certificate  from  a  physician 


23 

(and  a  certificate  from  the  Health  Department  showing  that  no  cases 
of  pohomyelitis  have  been  reported  at  the  address  given)  before  being 
admitted  to  contact  with  the  other  children.  An  inspector  of  the 
Health  Department  must  also  examine  the  child  on  the  day  of  its 
admission  to  the  institution,  and  again  before  allowing  it  to  return 
home. 

On  July  5th,  specific  instructions  were  issued  to  the  inspectors  and 
nurses  in  charge  of  the  59  Baby  Health  Stations  and  these  were  further 
supplemented  on  July  10th. 

1.  All  known  or  suspected  cases  of  anterior  poliomyelitis  coming 
to  your  attention,  are  to  be  reported  to  this  office  on  the  white  filing 
card,  giving  the  name,  age,  address,  floor,  duration  of  illness,  and 
name  and  address  of  physician  in  attendance. 

Prior   to   this   written   communication,   please  telephone   to  the 

clerk-in-charge  of  the  Division  of   School   Medical  Inspection,  the 

above  particulars,  and  note  on  the  filing  card  above  mentioned,  the 
fact  of  such  telephonic  communication. 

2.  In  cases  Avhere  anterior  poliomyelitis  exists  in  the  family,  the 
babies  may  be  enrolled,  but  they  must  not  be  allowed  to  visit  the 
station. 

The  mother  or  other  member  of  the  family  may  secure  milk  at 
the  station,  and  if  advice  and  instruction  are  necessary,  the  inspector 
or  nurse  should  visit  the  home. 

This  situation  is  to  be  treated  as  are  other  contagious  diseases, 
at  present. 

3.  Babies  living  in  houses  in  which  anterior  poliomyelitis  exists 
but  not  in  the  same  family,  may  be  enrolled  in  the  regular  manner. 

During  this  epidemiic  all  the  nurses  and  inspectors  should  impress 
the  mothers  with  the  necessity  of  absolute  personal  and  home  cleanli- 
ness, with  the  danger  of  allowing  refuse  to  remain  around  the  house, 
with  the  importance  of  covering  garbage  cans,  the  necessity  of  keep- 
ing children  away  from  others  as  much  as  possible ;  the  dangers  of 
coughing,  sneezing  and  expectoration ;  the  danger  of  flies  as  trans- 
mitters of  the  disease:  the  importance  of  nasal  hygiene;  the  advisabil- 
ity of  securing  immediate  medical  care  when  the  child  is  taken  ill, 
especially  with  fever,  vomiting,  drowsiness  or  weakness  of  the  ex- 
tremities, and  of  isolating  such  a  child  from  the  rest  of  the  family. 

Impress,  furthermore,  upon  the  parents,  the  importance  of  quar- 
antine, in  true  cases,  and  ask  them  to  report  to  you  any  suspicious 
cases  which  come  to  their  attention. 

Each  and  every  one  should  feel  her  personal  responsibility  in  the 
effort  which  is  being  made  to  control  an  epidemic  which  threatens  to 
assume  large  proportions. 

All  contemplated  outings  of  mothers  and  babies  must  be  can- 
celled. 

(July  10th) 

1.  Look  over  the  daily  list  of  contagious  diseases  immediately 
upon  your  arrival  at  the  station  each  morning,  and  note  the  name 
and  address  of  all  cases  of  anterior  poliomyelitis  listed  in  your  station 
district. 

2.  Record  on  a  large  sheet,  in  alphabetical  or  street  order,  the 
name  and  address  of  every  case  of  anterior  poliomyelitis  recorded  on 


24 

the  lists  since  June  1,  1916,  and  continue  this  daily  until  further 
notice,  adding  such  names  as  appear  on  the  daily  contagious  disease 
lists. 

3.  Arrange  to  have  mothers  or  other  members  of  families  in 
which  a  case  of  anterior  poHomyelitis  exists,  and  who  visit  the  station 
for  the  purpose  of  obtaining  milk,  call  for  the  milk  either  early  in  the 
morning  or  at  the  close  of  the  morning.  See  to  it  that  the  milk  is 
given  to  them  at  once,  and  that  they  leave  the  station  immediately. 
Under  no  circumstances  must  persons  living  in  infected  premises, 
who  come  for  milk,  be  permitted  to  mingle  unduly  with  the  regular 
clientele. 

4.  Enrolled  babies  from  infected  houses,  but  not  from  infected 
families,  must  be  instructed  and  treated,  and  given  preference  over 
others  in  attendance  at  the  station,  and  thus  disposed  of  as  quickly 
as  possible. 

'  5.  All  employees — inspectors,  nurses,  nurses'  assistants — must 
report  immediately  by  telephone  to  the  clerk-in-charge  of  the  Divi- 
sion of  School  Medical  Inspection  the  name,  address,  floor,  duration 
of  illness,  and  name  of  physician  in  attendance,  if  any,  of  all  non- 
placarded  true  or  suspicious  cases  of  poliomyelitis  coming  to  their 
attention.  This  clerk  will  telephone  report  of  case  to  the  Bureau  of 
Preventable  Diseases.  If  corroboration  of  diagnosis  is  necessary,  the 
inspector  or -supervisor  should  visit  the  home.  This  telephonic  com- 
munication must  be  followed  by  a  full  statement  of  the  above  par- 
ticulars on  a  white  filing  card,  and  forwarded  to  the  Central  Office, 
Division  of  Baby  Welfare. 

6.  All  employees,  when  making  home  visits,  must  instruct  and 
advise  the  public  in  preventive  measures,  as  outlined  in  the  instruc- 
tions under  date  of  July  5,  1916. 

7.  Should  any  child  ill  with  anterior  poliomyelitis  visit  the  sta- 
tion, he  or  she  must  be  excluded  at  once,  the  particulars  of  the  case 
telephoned  immediately  as  above  outlined,  and  the  mother  instructed 
to  take  the  child  home  and  isolate  it  from  other  members  of  the 
family. 

United   States    Public   Health    Service   Assigns    Special    Corps   of 

Investigators. 

On  July  6th,  the  Secretary  of  the  Treasury  in  person  offered  to  the 
Mayor  the  assistance  and  co-operation  of  the  United  States  Public  Health 
Service.  The  ofifer,  which  was  gratefully  accepted,  resulted  in  the  assign- 
ment of  eleven  officers,  one  epidemiologist,  and  one  biologist  to  the  work  in 
and  about  New  York  City.  By  conference  between  the  officers  in  charge 
and  the  Department  of  Health,  it  was  agreed  that  the  Public  Health  Service 
should  undertake  certain  field  and  statistical  studies  of  the  disease  for  which 
the  Department  of  Health  was  not  at  that  time  equipped  and  for  which 
the  personnel  of  the  Public  Health  Service  was  exceptionally  well  qualified. 

Laboratory  studies  were  found  impracticable  for  various  reasons  and 
this  phase  of  the  investigation  by  the  Public  Health  Service  was  carried 
on  at  the  Hygienic  Laboratory  at  Washington,  D.  C,  with  material  sent  from 
New  York  City.     It  would  be  inappropriate  to  include  in  the  report  of  the 


25 

Department  of  Health  of  New  York  City  the  results  of  these  admirable 
studies  which  will  appear  in  the  official  reports  of  the  Public  Health  Service. 
We  have  been  allowed,  however,  to  publish  as  part  of  this  report  the 
statistical  tables  prepared  by  these  collaborators. 

Statement  by  the  Mayor. 

On  July  9th  the  Mayor  called  a  conference  of  his  commissioners  to 
consider  in  what  ways  the  entire  force  of  the  City  Government  might  be 
used  for  protection  of  the  public.  The  departments  particularly  concerned, 
in  addition  to  the  Health  Department,  were  the  Police  Department,  Tene- 
ment House  Department,  Department  of  Street  Cleaning  and  Department  of 
Water  Supply,  Gas  and  Electricity. 

The  following  statement  was  issued  in  the  press  the  next  morning  and 
did  much  to  quiet  the  growing  public  alarm,  and  give  confidence  that  no 
effort  would  be  spared  : 

"  All  Resources  of  the  City  Mobilized  in  Fight  Against  Paralysis. 

"  Although  very  little  is  known  of  the  origin  or  transmission  of 
infantile  paralysis,  I  am  advised  by  the  health  authorities  that  all 
scientific  experience  points  to  the  fact  that  it  is  communicated  by 
direct  personal  contact,  and  that  the  germs  do  not  live  apart  from 
the  human  body;  in  other  words,  that  it  is  necessary  for  a  diseased 
person,  or  one  who  has  been  in  contact  with  a  diseased  person  to 
come  in  turn  into  contact  with  a  susceptible  individual  in  order  that 
the  disease  be  communicated. 

"  Cases  Segregated.  The  Health  Department  is  now  bending 
every  energy  night  and  day  to  prevent  the  spread  of  the  infection 
through  such  contacts  as  just  described.  This  it  is  doing  by  segre- 
gating the  cases  in  hospitals,  as  rapidly  as  the  diagnosis  can  be  posi- 
tively made,  and  by  educating  the  people  in  the  method  of  preventing 
personal  contact  by  personal  cleanliness. 

"  At  the  same  time,  we  have  called  into  co-operation  the  national 
health  services  to  aid  in  tracing  the  origin  of  this  epidemic,  and  in 
determining  more  accurately  than  our  present  knowledge  permits, 
the  method  of  transmitting  the  disease. 

"  In  the  meantime,  and  whatever  the  method  of  transmission  may 
be,  I  have  determined  that  every  precautionary  measure  in  the  nature 
of  clearing  out  refuse  from  halls,  areas,  yards  and  cellars,  its  collec- 
tion and  immediate  removal  from  the  streets  shall  be  taken  in  so  far 
as  the  city  government  has  the  power  to  enforce  the  action. 

"Accumulations  of  refuse  containing  garbage  in  the  public 
streets  at  various  points  in  the  congested  districts  have  been  reported 
during  the  last  few  days.  These  are  conditions  that  exist  continu- 
ously in  the  congested  districts  and  are  solely  the  product  of  viola- 
tions of  city  ordinances  by  householders,  who,  despite  repeated  warn- 
ings and  all  that  we  can' do  to  the  contrary,  insist  on  throwing  the 
refuse  into  the  streets  in  place  of  collecting  it  in  proper  receptacles 
as  provided  by  law.  A  real  city  clean-up,  with  the  maintenance  of 
cleanly  conditions,  can  be  effected  only  if  householders  will  co-op- 


26 

erate  by  observing  these  ordinances  forbidding  the  spreading  of 
refuse  in  the  streets. 

"  Receptacles  for  Garbage.  I  wish  to  make  it  perfectly  clear  that 
the  Street  Cleaning  Department  is  not  responsible  for  the  refuse 
which  can  be  found  any  morning  lying  in  the  streets  of  the  congested 
districts,  and  that  it  discharges  its  duty  by  removing  that  refuse  as 
soon  as  the  carts  and  men  of  the  department  reach  these  streets  in 
the  course  of  their  regular  day's  work. 

"  Householders  are  also  required  by  law  to  maintain  watertight 
and  properly  covered  metal  receptacles  for  garbage,  and  to  deposit 
rubbish  securely  tied  in  bundles  so  that  it  will  not  spread  over  the 
streets. 

"  I  have  directed  the  Police  Department  to  enforce  rigidly  these 
ordinances.  I  have  specifically  directed  that  any  householder,  store- 
keeper or  other  person  found  depositing  garbage  or  rubbish  in  the 
streets  in  violation  of  these  ordinances  is  to  be  arrested  and  arraigned 
before  a  Magistrate.  I  am  requesting  the  Chief  City  Magistrate  to 
urge  all  Magistrates  in  the  city  to  co-operate  with  the  city  authorities 
in  enforcing  the  law,  and  to  impress  its  importance  upon  violators  by 
adequate  penalties. 

"  I  have  further  directed  the  Tenement  House  Commissioner  to 
utilize  all  the  resources  of  his  department  to  compel  the  cleaning  up 
of  halls,  areaways,  cellars  and  yards  throughout  the  city. 

"  I  have  directed  the  Street  Cleaning  Commissioner  to  accelerate 
to  the  limit  of  possibility  the  collection  of  garbage,  ashes  and  refuse 
properly  deposited  in  receptacles  and  to  continue  to  clean  from  the 
streets  such  refuse  as  may  be  thrown  there  in  violation  of  law.  This 
is  done  by  the  Street  Cleaning  Department  every  day  at  the  present 
time,  but  we  propose  to  attempt  to  complete  the  work  somewhat 
earlier  each  day  than  at  present. 

"  More  Water  for  Streets.  There  is  no  more  important  feature 
of  the  work  of  the  Department  of  Street  Cleaning  at  the  present  time 
than  that  of  street  flushing.  This  is  a  very  useful  way  of  using 
water,  provided  it  be  not  wasted.  Every  possible  effort  is  made  to 
supervise  the  individual  street  cleaners  so  that  they  shall  not  use  the 
hose  longer  than  necessary  on  any  one  spot,  though  it  is  unfortunately 
often  difficult  to  control  their  individual  operations.  In  due  course 
it  is  hoped  to  rectify  this  condition.  Meanwhile  it  should  be  re- 
membered that  not  over  one  per  cent,  of  the  total  amount  of  water 
consumed  daily  is  used  for  street  cleaning,  while  elsewhere  amongst 
private  consumers  there  is  a  preventable  waste  of  from  ten  per  cent, 
to  fifteen  per  cent,  of  such  total. 

"  The  Department  of  Water  Supply  has  been  co-operating  with 
the  Department  of  Street  Cleaning  in  this  matter  throughout  the 
present  administration.  I  have  directed  its  further  co-operation  in 
the  present  situation  in  order  that  still  more  water  may  be  available 
to  the  Street  Cleaning  Department,  to  the  end  that  the  streets  includ- 
ing sidewalks  particularly  in  congested  districts  shall  be  thoroughly 
washed  down  each  day. 

"  The  Street  Cleaning  Department  will  increase  its  night  work  in 
Manhattan,  so  that  every  street  will  be  cleaned  every  night.  In 
Brooklyn  where  the  epidemic  has  been  most  severe,  a  number  of 
hose  gangs  employed  in  night  flushing  will  be  increased  from  15  to 


27 

40  in  the  infected  area.  Night  work  will  be  increased  by  50  per  cent. 
To  do  this  the  Street  Cleaning  Department  must  reduce  its  force 
employed  in  the  daytime  and  unless  property  owners  will  co-operate 
by  avoiding  the  present  general  widespread  violation  of  ordinances  in 
the  matter  of  littering  the  streets  with  refuse,  there  undoubtedly  will 
be  an  increase  in  the  unsightly  appearance  of  streets  during  the  day- 
time. Here  I  expect  particularly  the  co-operation  of  the  Police  De- 
partment through  the  rigorous  enforcement  of  the  ordinances. 

"  In  short,  it  will  be  the  effort  of  the  city  government  during  the 
continuance  of  the  epidemic  of  infantile  paralysis  to  focus  all  its 
forces  on  a  general  clean-up  as  a  means  of  reducing  the  possibility 
of  the  spread  of  the  disease.  Resources  of  the  Health  Department, 
Street  Cleaning  Department,  Police  Department  and  the  Department 
of  Water  Supply  and  the  Tenement  House  Department  will  all  be 
employed  to  this  end. 

"  There  is  no  occasion  for  alarm  or  panic.  The  careful  observ- 
ance of  the  simple  directions  given  by  the  Health  Department  as  to 
personal  and  household  cleanliness  will  go  far  to  prevent  further 
spread  of  or  exposure  to  infection. 

"  I  wish  to  urge  citizens  to  permit  the  removal  of  their  sick  chil- 
dren to  hospitals  selected  by  the  Department  of  Health.  The  death 
rate  in  this  epidemic  has  been  appreciably  lower  in  hospitals  to  which 
patients  are  taken  for  the  sake  of  isolation  than  in  patients'  homes 
where  adequate  care  cannot  be  provided." 

The  result  of  effective  co-operation  was  soon  evident,  and,  according  to 
the  critical  opinion  of  the  inspectors  of  city  departments  and  of  careful  and 
observant  citizens,  the  highways  and  premises  of  the  city  were  never  in  so 
clean  and  wholesome  a  condition  as  everywhere  prevailed  through  the  re- 
mainder of  the  summer. 

Private  Hospitals  Co-operate. 

On  July  10th  it  became  quite  apparent  that  with  at  least  four  weeks 
rnore  of  increase  in  the  number  of  cases  to  be  expected,  and  a  daily  report 
of  about  100  cases,  the  capacity  of  the  hospitals  of  the  Department  of 
Health  would  soon  be  reached  and  either  additional  hospital  beds  must  be 
obtained,  or  the  policy  of  hospitalizing  the  cases  must  be  abandoned.  The 
hospitals  of  the  city  were  appealed  to  by  the  Mayor,  and  within  a  week 
enough  beds  had  been  promised  to  accommodate  the  expected  census  of 
patients. 

Separate  wards  were  in  most  cases  made  available  and  conducted  ac- 
cording  to  established  practice  for  the  care  of  communicable  diseases.  In 
two  notable  instances,  complete  hospital  establishments  were  put  at  the  dis- 
posal of  the  Department  of  Health.  The  Health  Officer  of  the  Port  offered 
the  use,  for  patients  from  the  Borough  of  Richmond,  of  the  isolation  hos- 
pital at  Swinburne  Island,  with  a  capacity  of  75  patients.  With  certain 
supplies  and  personal  service  contributed  by  the  Department  of  Health,  the 
wards  were  immediately  made  available,  and  throughout  the  remainder  of 
the  epidemic  the  necessity  of  transferring  more  than  a  small  number  of 


28 

cases  from  Stateii  Island  to  Department  hospitals,  in  other  Boroughs,  was 
avoided.  The  New  York  Hospital,  having  its  children's  wards  filled  to 
capacity,  but  wishing  to  make  its  contribution  to  the  service  of  the  City, 
offered  to  occupy  and  maintain  a  hospital  with  one  hundred  and  six  beds 
in  the  building  recently  vacated  by  the  New  York  Orthopaedic  Hospital,  in 
East  59th  street.  The  use  of  the  building  was  given  to  the  New  York  Hos- 
pital, through  the  Department  of  Health,  by  the  Orthopaedic  Hospital,  and 
the  New  York  Hospital  promptly  installed  the  necessary  staff  and  equip- 
ment, even  to  the  point  of  establishing  a  pathological  laboratory  for  research 
purposes  at  the  hospital. 

The  public  spirit  and  resourcefulness  shown  by  the  28  hospitals,  which 
put  at  the  disposal  of  the  Department  of  Health  a  total  of  726  beds,  cannot 
be  too  highly  praised.  By  their  co-operation  they  played  an  important  part 
in  the  method  of  sanitary  control  of  the  disease  which  had  been  undertaken 
by  the  Health  Department.  Bellevue  Hospital  and  the  hospitals  of  the 
Department  of  Charities  provided  a  maximum  of  660  beds. 

No  attendant,  physician,  nurse  or  domestic,  and  no  patient  admitted  to 
any  of  the  hospitals  throughout  the  city,  for  other  cause  than  poliomyelitis, 
during  the  epidemic,  contracted  poliomyelitis.  This  has  been  the  almost 
universal  experience  in  the  past,  and  has  often  been  brought  forward  as  a 
proof  of  the  non-communicable  character  of  the  disease.  In  the  minds  of 
those  who  have  studied  the  disease  in  the  field,  this  experience  would  rather 
indicate  that  the  simple  methods  of  ward  cleanliness  and  the  usual  technique 
of  personal  care  employed  in  hospitals  suffices  to  prevent  communication  of 
the  disease,  and  this  opinion  is  borne  out  by  the  experience  in  institutions 
for  children  where  similar  simple  measures  prevented  the  spread  of  the 
disease.  One  of  the  field  nurses  of  the  Department  engaged  in  daily  house 
to  house  visits  among  the  families  where  active  cases  were  isolated  developed 
poliomyelitis  in  a  severe  paralytic  form. 

The  City  paid  at  established  rates  for  the  care  of  patients  admitted  to 
the  hospitals  above  mentioned.  A  complete  statistical  record  of  the  services 
of  these  hospitals  is  to  be  found  on  pages  261,  262,  and  263. 

Conference  of  Physicians  Called  by  the  Mayor. 

On  July  12th  the  Mayor  requested  the  opinion  of  members  of  the 
Advisory  Medical  Board  of  the  Board  of  Health,  and  of  a  number  of  other 
prominent  scientists  and  sanitarians  as  to  further  means  of  checking  the 
spread  of  the  epidemic.  A  sub-committee  was  appointed,  which  met  the 
following  day,  and  decided  that  no  further  administrative  or  educational 
measures  could  be  expected  to  produce  any  beneficial  results,  but  reported 
that  it  would  be  advisable  to  take  such  steps  as  might  prove  practicable!  to 
discover,  trace  and  keep  under  observation  persons  who  might  have  been  in 
immediate  contact  with  those  sick  with  the  disease.  In  other  words,  the 
sub-committee  advised  the  Mayor  that  some  additional  knowledge  might  be 


29 

expected  from  an  intensive  study  of  the  contacts  and  secondary  cases  occur- 
ring throughout  the  city.  Inasmuch)  as  this  was  in  the  nature  of  experi- 
mental field  work,  which  the  Department  of  Health  was  not  at  the  time  free 
to  undertake,  the  Mayor  accepted  the  offer  of  the  Rockefeller  Foundation 
to  defray  the  cost  of  the  proposed  investigation.  The  entire  personnel  of 
the  field  and  office  force,  together  with  the  director,  was  put  upon  the  pay- 
roll of  the  Department  of  Health,  and  the  funds  provided  by  the  Rockefeller 
Foundation  were  disbursed  through  the  Department  of  Health  on  vouchers 
signed  by  the  Director,  the  Vice-Chairman  of  the  committee  in  charge  (the 
Mayor,  Dr.  Simon  Flexner,  Vice-Chairman,  Dr.  Haven  Emerson,  Dr.  W.  B. 
James  and  Dr.  G.  R.  Butler)  and  by  the  Commissioner  of  Health.  The  work 
was  undertaken  soon  after  and  a  report  of  the  results  will  be  found  on 
page  111. 

On  July  13th  the  special  poliomyelitis  field  corps  of  the  Department 
was  further  increased  by  40  medical  inspectors  and  10  nurses. 

Travellers"  Certificates. 

On  July  14th  there  was  undertaken  for  the  first  time  a  new  procedure 
which  developed  into  such  large  proportions  and  caused  so  much  public 
comment,  chiefly  of  adverse  character,  that  it  deserves  special  mention. 
Owing  to  the  local  restrictions  adopted  by  various  health  boards  in  many 
adjacent  states  and  communities,  within  easy  travelling  distance  by  rail, 
boat,  or  motor,  from  New  York,  which  were  in  the  nature  of  honest  but 
impractical  attempts  to  ward  off  the  approach  of  infected  individuals  from 
New  York  City,  healthy  adults  and  children  from  the  city  were  subjected 
to  inconvenience,  great  injustice  and  even  to  inhuman  treatment.  Rail- 
roads and  other  common  carriers  appealed  for  assistance  and  it  was  de- 
cided that  so-called  health  certificates,  or  more  properly  travellers'  identifica- 
tion cards,  should  be  issued  to  those  who  presented  themselves  at  certain 
offices  of  the  Department  of  Health  for  medical  inspection  and  could  prove 
residence  at  an  address  from  which  no  case  of  poliomyelitis  had  as  yet  been 
reported.  Between  this  date  and  July  18th  these  certificates  were  issued  by 
the  Department  of  Health,  and  only  after  examination  of  the  applicant  by 
a  physician  of  the  Department.  On  July  18th,  25  offifcers  of  the  Public 
Health  Service  were  assigned  by  the  Surgeon  General  to  the  control  of  inter- 
state transportation  in  the  interest  of  preventing  the  spread  of  the  disease. 
Later,  twelve  more  physicians  were  added  to  this  staff,  all  operating  under 
Senior  Surgeon  Charles  E.  Batiks.  The  supervision  of  travel,  as  enforced 
under  the  provisions  of  the  interstate  quarantine  regulations,  was  as  fol- 
lows (extract  from  report  of  Senior  Surgeon  Banks)  : 

"  Children  16  years  of  age,  and  under,  were  placed  in  a  class  of 
restricted  travel  and  were  not  permitted  to  leave  the  city  from  July 
18th  until  October  3d,  without  producing  a  certificate  that  the  prem- 
ises occupied  by  them  were  free  from  poliomyelitis,  and  had  been 


30 

free  from  this  disease  since  January  1,  1916.  This  was  supple- 
mented by  a  medical  examination  of  such  travellers  at  the  point  of 
departure.  When  these  requirements  were  satisfactorily  shown,  a 
certificate  of  identification  was  issued,  together  with  a  duplicate  of 
same  immediately  mailed  to  the  health  officer  of  the  community  to 
which  the  travellers  were  destined.  As  required  by  law,  common 
carriers  (railroads,  steamboats,  etc.)  were  obliged  to  refuse  entrance 
to  trains  or  boats  of  this  restricted  class  unless  so  provided  with  the 
certificates.  The  essential  basis  of  this  certification  was  the  informa- 
tion furnished  by  the  New  York  City  Board  of  Health  covering  the 
immune  condition  of  the  premises  of  intending  travellers,  and  full 
credence  was  given  to  this  aid  in  the  execution  of  the  measures 
undertaken  by  the  Public  Health  Service  in  preventing  the  spread  of 
the  disease  through  interstate  travel. 

"  These  regulations  were  enforced  at  every  rail  or  ferry  termi- 
nal, and  steamboat  pier,  in  New  York  City,  and  as  far  as  possible 
automobile  traffic  leaving  the  city  by  other  avenues  was  included." 

The  objects  achieved,  from  the  standpoint  of  those  engaged  in  this 
work  in  New  York  City,  may  be  stated  as  warranting  the  following  con- 
clusions : 

First.  There  resulted  a  stabilization  of  public  opinion  through  the  pres- 
ence of  regular  officers  of  the  United  States  Public  Health  Service,  trained  in 
the  management  of  epidemics,  who  were  assigned  to  duty  in  New  York  City. 
This  was  crystallized  through  the  uniform  approval  of  the  metropolitan 
press,  with  its  continuous  favorable  references  to  the  work  accomplished. 

Second.  The  work  affected  a  standardization  of  methods  adopted  by 
local  quarantine  officers  of  other  states  through  co-operation  with  the  plan  of 
certification  above  described.  Harsh  restrictive  measures  had  been  adopted 
in  many  localities  because  of  the  absence  of  knowledge  of  the  extent  of  the 
epidemic  and  lack  of  information  of  the  origin  of  travel  into  their  com- 
munities. 

Third.  It  afforded  the  local  health  authorities  a  certain  security  in 
locating  arrivals  in  their  jurisdiction  immediately,  and  instituting  such  meas- 
ures of  isolation,  or  limitation  of  movements  for  a  given  period  as  they 
deemed  wise. 

Finally,  it  constituted  a  demonstration  of  the  need  of  a  centralized  au- 
thority, with  power  to  deal  with  interstate  problems  relating  to  the  trans- 
mission of  disease  by  common  carriers,  backed  by  congressional  statute. 
The  Quarantine  Law  of  February  15,  1893,  was  the  keynote  to  the  adminis- 
tration of  the  work  of  the  officers  of  the  United  States  Public  Health  Service 
in  the  measure  employed  by  it  of  certification  and  notification  to  health 
officers  of  travel  to  their  localities. 


31 

Form  of  Travellers'  Idextificatiox  Certificate  Issued. 


Depart 

MEXT  OF  Health 

ClTY 

OF  Xew  York 

I  hereby  apph 

•  for  a 

certificate  that  there  has  been 

no 

case  of  poliomyelitis  at  my  address 

•  -, 

Borough  of .  .  . 

(Signature  of  Applicant) 

This  is  to  certify  that  the  records  of  the  Department 

of 

Health  of  the 

City  of 

Xe\y  York  show  that  no  case 

of 

poliomyelitis  has  been 

reported  from 

Borough  of.  .  . 

Date 

..,  1916.     Issued  by 

(^Xame  and  Title  j 

On  July  15th  the  Police  Department  was  requested  to  report  all  re- 
movals of  families  within  the  city  or  to  points  outside,  so  as  to  facilitate 
the  tracing  of  contacts  and  reported  cases  which  disappeared  before  the 
diagnosis  w^as  confirmed. 

On  July  20th  it  was  found  necessary  to  follow  up  the  cases  isolated  in 
their  homes  with  much  more  care,  as  repeated  instances  of  violation  of 
quarantine  were  reponed.  To  this  end,  35  motorcycle  police,  obtained  by 
a  call  for  A'olunteers,  were  assigned  by  the  Police  Commissioner  to  the 
Health  Department.  They  called  on  all  home  cases  every  other  day,  alter- 
nating with  the  visits  of  field  nurses  of  the  Department  of  Health. 

Coxtrol  of  Playgrouxds. 

This  day  saw  also  an  organized  efifort,  for  the  recreational  facilities 
for  children,  take  definite  form  and  produce  substantial  results,  as  con- 
fidence in  the  safety  of  the  playgrounds  took  the  place  of  suspicion  and 
panic.  As  soon  as  the  quarantine  regulations  in  regard  to  poliomyelitis 
were  put  into  effect,  it  became  increasingly  evident  that  the  usual  work 
performed  by  the  Department  of  Health  and  various  agencies  of  the  city, 
relative  to  fresh  air  outings  for  children,  would  be  appreciably  checked. 
In  fact,  almost  immediately  towns  outside  Xew  York  City  refused  to  accept 
any  children  sent  from  the  city.  In  consequence,  summer  camps  were 
closed,  fresh  air  outings  stopped,  and,  in  many  instances,  children  were 
barred  from  playgrounds  and  public  baths. 


32 

All  child-welfare  workers  were  keenly  alive  to  the  danger  that  threat- 
ened, and  the  Fresh  Air  Federation  of  New  York  took  immediate  steps  to 
meet  the  situation.  The  Department  of  Health,  in  co-operating  with  this 
federation,  devised  ways  and  means  whereby  substitutes  were  found  for  the 
fresh  air  outings  so  generally  relied  upon  during  previous  summers.  The 
reports  of  the  various  settlements  and  of  the  Fresh  Air  Federation  of  New 
York  will  give  in  detail  the  individual  work  done  by  these  organizations. 

In  this  survey  it  is  only  necessary  to  state  that,  while  a  far  greater 
number  of  children  were  kept  in  town  during  the  summer  than  during  previ- 
ous summers,  it  was  possible,  through  the  joint  efforts  of  the  Fresh  Air 
Federation,  the  Department  of  Health  and  the  Department  of  Education 
to  open  public  shower  baths  in  the  various  schools  of  New  York  City.  In 
this  work  the  Bath  Committee  of  the  office  of  the  Borough  President  of 
Manhattan  co-operated  very  closely  and  the  Board  of  Education's  Com- 
mittee on  Care  of  School  Buildings  was  informed  that  the  Fresh  Air  Federa- 
tion was  willing  to  operate  the  school  baths  if  permission  could  be  obtained 
simply  to  open  the  school  buildings  for  the  purpose.  It  was  found  that 
about  forty  of  the  public  schools  in  Manhattan  were  equipped  with  shower 
baths  but  that  the  program  of  the  Board  of  Education  provided  for  the 
opening  of  only  about  half  this  number.  Under  the  auspices  of  the  Board 
of  Education  there  were  twenty-two  baths  in  Manhattan,  one  in  The  Bronx 
and  seven  in  Brooklyn  open  for  the  summer  of  1916.  Through  the  efiforts 
of  the  Fresh  Air  Federation,  eight  additional  baths  were  opened.  In  addi- 
tion, all  baths  operated  by  settlements  were  widely  used. 

Energetic  efforts  were  made  by  the  Fresh  Air  Federation  to  increase 
the  out-of-town  facilities  for  fresh  air  parties,  but  marked  resistance  was 
met  in  this  direction.  Quarantine  against  New  York  was  rigidly  main- 
tained by  practically  every  town  within  reasonable  distance  of  New  York 
City,  and  the  only  solution  of  the  problem  seemed  to  be  educational  work 
which  would  induce  mothers  to  take  their  children  outdoors,  and  the  provi- 
sion of  proper  play  space.  Such  work  was  carried  on  with  vigor  by  the 
Department  of  Health  and  the  various  fresh  air  agencies. 

During  the  early  part  of  the  summer,  the  authorities  in  charge  of  the 
various  playgrounds  and  recreation  centres  for  children  of  the  city  were 
impressed  by  the  possible  danger  that  these  places  afforded  for  the  means 
of  transmitting  poliomyehtis,  consequently  a  considerable  number  of  them 
were  closed,  although  no  order  had  been  issued  by  the  Department  of  Health 
to  this  effect.  As  it  was  felt  that  the  use  of  these  recreation  centres  was 
of  the  utmost  importance  in  providing  the  necessary  fresh  air  and  play 
space  for  children,  investigation  was  made  by  the  Department  of  Health 
to  determine  whether  or  not  the  playgrounds  and  centres  were  being  oper- 
ated in  accordance  with  the  regulations  of  the  Department  of  Health,  rela- 
tive to  (1)  the  use  of  the  daily  contagious  disease  lists  and  (2)  the  provi- 
sion of  proper  medical  supervision. 

It  was  determined  that  these  playgrounds  and  recreation  centres  could 


33 

be  safely  operated  under  the  supervision  of  the  Department.  Accordingly, 
investigation  was  made  of  each  playground.  Careful  instructions  were  given 
to  the  authorities  in  charge  of  the  playgrounds  to  the  effect  that,  each  morn- 
ing, the  daily  list  of  contagious  diseases  must  be  carefully  checked  up  with 
relation  to  each  child  admitted  to  the  playground  on  that  day,  and  that 
every  child  belonging  to  a  family  in  which  a  case  of  infectious  disease  had 
occurred  must  be  excluded  from  attendance  at  the  playground.  The  follow- 
ing instructions  were  also  given  to  those  in  charge  of  the  pla3'^grounds  and 
centres : 

1.  A  competent  person,  such  as  a  graduate  or  well-trained 
under-graduate  nurse,  should  be  employed  at  each  centre  to  inspect 
the  children  each  day.  Any  child  showing  signs  or  symptoms  of  any 
illness  whatsoever  must  be  immediately  excluded  from  attendance 
at  the  centre  and  the  facts  reported  to  the  Department  of  Health, 
giving  name,  address  and  reason  for  exclusion. 

2.  In  the  supervision  of  children  at  play  centres,  the  following 
points  must  be  observed : 

(a)  Sand  boxes  are  not  to  be  used. 

(b)  Children  should  play  in  small  groups. 

(c)  Games  involving  bodily  contact-are  not  to  be  allowed. 

The  authorities  of  the  playgrounds  were  also  informed  that  the  De- 
partment of  Health  could  not  provide  the  necessary  medical  and  nursing 
supervision  and  that  the  authorities  must  provide  the  daily  inspection  re- 
quired, that  there  must  be  a  nurse  or  physician  connected  with  the  play- 
ground to  whom  debatable  questions  might  be  referred. 

Those  in  charge  of  these  various  centres  were  notified  that  failure  to 
observe  the  orders  issued  would  result  in  the  immediate  closing  of  the  play 
centre.  It  is  of  interest  to  note  that  during  the  entire  summer  no  instances 
of  violations  were  reported  nor  were  any  instances  of  the  transmission  of 
infectious  disease  noted,  although  careful  inquiry  was  made  regarding  this 
point. 

Owing  to  the  fact  that  during  the  early  summer  few,  if  any,  children 
went  to  the  playgrounds,  it  is  not  surprising  that  the  attendance  was  con- 
siderably lower  than  during  the  same  period  of  1915.  The  exact  statistics 
are  given  herewith : 

No.  of  playgrounds  maintained 

Playgrounds  open    

Playgrounds    closed    

Total   attendance    

Conference  of  Scientists  Requested  by  the  Board  of  Estimate  and 

Apportionment. 

On  July  27th  a  special  appropriation  was  made  by  the  Board  of  Esti- 
mate and  Apportionment,  at  the  request  of  the  Department  of  Health  for 
funds  to  defray  the  expenses  of  scientists,  whom  it  was  thought  necessary 


1915. 

1916. 

193 

177 

July  5 

Tulv  3 

Aug.  17 

Aug.  18 

K089,977 

2,726,216 

34 

to  invite,  to  give  the  Department  of  Health  ^e  benefit  of  all  information 
and  their  judgment  on  the  management  of  the  epidemic. 

On  August  3d  there  assembled,  at  the  invitation  of  the  Board  of  Esti- 
mate and  Apportionment,  a  notable  group  of  the  ablest  investigators  in  the 
field  of  experimental  medicine  and  leaders  in  the  science  of  prevention  of 
disease.  Every  facility  was  given  them  to  learn  the  exact  situation  in  New 
York  City  from  a  detailed  description  of  the  epidemic  to  date,  and  by  per- 
sonal study  in  the  field,  in  hospitals  and  in  the  laboratories  of  the  city. 
Their  report  follows : 

Report  of  the  Conference  Committee  on  Poliomyelitis. 

"  Dr.  Haven  Emerson, 

"  Commissioner  of  Health, 
"  City  of  New  York. 

"  Dear  Sir — Having  been  called  to  New  York  at  your  sugges- 
tion and  for  the  purpose  of  consulting  with  you  concerning  the 
practical  measures  employed  in  dealing  with  the  present  epidemic  of 
poliomyelitis,  we  offer  the  following  statement : 

"  We  have  spent  two  days  in  studying  the  situation  and  investi- 
gating prevailing  conditions. 

"  On  Thursday  morning,  August  3d,  we  went  over  with  you 
the  history  of  the  origin  and  spread  of  the  epidemic  of  this  year. 
We  made  a  careful  study  of  your  maps  and  diagrams  showing  the 
number  and  distribution  of  cases  in  the  different  boroughs  of  the 
city.  This  was  followed  by  a  discussion  of  the  methods  that  have 
been  employed  both  here  and  elsewhere  in  attempts  to  control  the 
spread  of  the  disease. 

"  In  the  afternoon  of  the  same  day  we  visited  Willard  Parker 
Hospital  and  made  a  careful  inspection  of  the  treatment  and  care 
given  by  the  city  to  the  children  afflicted  with  this  disease. 

"  Thursday  evening  we  had  a  discussion  concerning  the  methods 
being  employed  and  the  possibility  of  making  these  more  efficient. 

"  On  Friday  morning,  August  4th,  we  visited  cases  quarantined 
in  their  own  homes  and  in  this  way  were  able  to  compare  the  hospital 
care  with  the  home  care  of  the  sick.  We  also  made  a  survey  of  cer- 
tain crowded  infected  districts  and  with  a  diagnostician  we  visited 
certain  homes  in  which  cases  have  been  recently  reported. 

"  Friday  afternoon  we  gave  to  a  more  formal  discussion  and  the 
suggestion  of  definite  recommendations. 

"  We  have  given  special  attention  to  the  methods  now  employed 
by  you  and  your  department  and  we  approve  of  the  measures  you 
have  taken. 

"  The  weight  of  opinion  favors  the  view  that  infantile  paralysis 
is  mainly  spread  through  personal  contact,  and  measures  have  been 
directed  chiefly  from  this  point  of  view.  Cognizance,  however,  has 
been  given  to  additional  methods  of  transmission,  among  which  is 
the  bite  of  insects.  For  sanitary  purposes  it  is  proper  to  consider 
that  this  disease  is  transmissible  directly  from  the  sick  to  susceptible 
persons  or  indirectly  from  the  sick  through  carriers. 


35 

'''  Even  with  our  incomplete  knowledge  of  the  dissemination  of 
the  disease,  it  is  evident  that  in  seeking  to  abate  the  epidemic  stress 
must  be  specially  laid  upon  two  things,  as  is  now  being  done : 

"  1.     The  early  recognition  and  notification  of  the  disease,  and 

"'2.  The  immediate  isolation  of  patients  and  cases  of  suspicious 
illness. 

■■  Furthermore,  on  account  of  incomplete  knowledge  concerning 
the  disease,  measures  known  to  be  eitective  in  checking  the  spread  of 
other  infections  should  be  applied  and  these  are,  particularly,  per- 
sonal hygiene,  cleanliness  of  person  and  surroundings  and  care  of 
food,  which  should  be  thoroughly  cooked. 

"  In  order  to  secure  the  earliest  possible  recognition  and  notifica- 
tion of  cases  and  their  prompt  isolation,  we  wish  to  direct  particular 
attention  to  the  appeals  that  have  been  made  by  the  department  to 
the  physicians  of  the  city  and  the  public  generally  that  they  co-operate 
with  the  department  in  all  these  measures. 

'■'  We  strongly  recommend  that  you  inaugurate  a  house  to  house 
inspection  of  as  large  a  part  of  the  city  as  is  practicable  twice  a  week, 
for  the  purpose  of  educating  and  of  securing  the  early  recognition, 
notification,  and  isolation  of  the  disease. 

■■  We  are  of  the  opinion  that  satisfactory  isolation  is  secured 
only  in  hospitals.  Moreover,  not  only  is  more  thorough  protection 
secured  for  the  public  by  the  hospitalization  of  patients,  but  it  is  also 
better  for  the  individual  patient. 

"  There  is  still  much  to  be  learned  concerning  the  period  of  in- 
cubation, accurate  methods  of  early  diagnosis  in  non-paralytic  cases, 
modes  of  transmission  and  the  length  of  time  persons  continue  to 
carry  the  infection,  and  in  view  of  these  factors,  a  scientifically  ade- 
quate method  of  control  is  impossible  at  the  present  time. 

"'  The  committee  recommends  the  closest  co-operation  possible 
among  the  different  laboratories  and  investigators  that  may  under- 
take the  investigation  of  problems  connected  with  epidemic  polio- 
myelitis. 

"  The  Committee  would  suggest  the  following  problems  as  espe- 
cially desirable  for  investigation  at  this  time : 

•■'■  1.  }vIethods  of  culture  of  the  virus  of  poliomyelitis,  with  espe- 
cial reference  to  corroboration  of  previous  work,  to  simplification  of 
methods,  and  to  the  distribution  of  the  virus  in  the  body  of  patients. 

"2.  The  immunologic  reactions  of  patients  and  supposed  car- 
riers of  the  virus,  and  others. 

■■■■  3.  The  virulence  in  animals,  of  the  crude  virus,  in  order  to 
determine  if  possible  whether  there  are  any  difi"erences  in  the  virus 
causing  outbreaks  in  different  parts  of  the  country  as  well  as  to  dis- 
cover perchance  more  susceptible  animals  for  experimental  purposes 
than  are  now  available. 

"4.  The  microscopic  study  of  the  secretions  of  the  nose  and 
throat  and  of  the  intestinal  contents  of  patients  suffering  from  ppHo- 
myelitis,  persons  who  have  come  in  close  contact  with  such  patients 
and  others. 


36 

"  5.     The  transmission  of  the  disease  by  insects  and  domestic 
animals  and  other  possible  modes  of  transmission. 

"6.     The  study  of  practical  methods  of  disinfection  , 

(Signed) 

Dr.  J.  F.  Anderson  Prof.  J.  W.  Jobling  Dr.  Francis  W.  Peabody 

Prof.  C.  C.  Bass  Prof.  L.  Hektoen  Prof.  Richard  Pearce 

Dr.  George  Draper  Dr.  C.  H.  Lavinder  Prof.  M.  J.  Rosenau 

Dr.  Simon  Flexner  Prof.  Paul  A.  Lewis  Prof.  Theobald  Smith 

Dr.  W.  H.  Frost  Dr.  E.  Libman  Prof.  Victor  C.  Vaughan 

Dr.  Joseph  Goldberger  Dr.  G.  W.  McCoy  Prof.  Hans.  Zinsser 

Prof.  John  Rowland  Dr.  Hideyo  Noguchi  Dr.  A.  Wadsworth 

The  immediate  result  of  the  recommendations  was  the  organization  of 
house  to  house  visits,  with  a  corps  of  nurses  under  the  direction  of  a  com- 
mittee representing  various  nursing  and  field  agencies,  life  insurance  com- 
panies and  the  Department  of  Health. 

Day  and  Week  of  Greatest  Incidence  of  the  Disease. 

The  day  upon  which  the  committee  of  visiting  scientists  first  met  fell 
upon  the  point  of  greatest  daily  incidence  of  the  disease,  according  to  the 
reports  of  cases  to  the  Department  of  Health.  Two  hundred  and  seventeen 
cases  were  reported  on  August  3d.  The  following  week,  August  5th  to 
12th,  also  recorded  the  greatest  number  of  cases  and  deaths  with  a  total  of 
1,151  cases  and  301  deaths  from  poliomyelitis.  From  this  time,  each  week 
showed  a  decrease  in  the  epidemic  until  on  November  6th  no  cases  or  deaths 
from  the  disease  were  reported.  Cases  have  occurred  in  small  num- 
bers each  week  since  this  time,  but  only  in  the  way  recognized  for  some 
years  past  as  characteristic  of  the  endemic  or  sporadic  expression  of  the 
disease. 

Permanent  Committee  on  After-Care  of  Infantile  Paralysis  Cases 

Organized. 

On  August  4th  the  patients,  in  whom  the  onset  had  occurred  before  the 
first  week  in  June,  were  already  reaching  the  end  of  the  period  of  isola- 
tion required  by  the  Department  (8  weeks),  and  in  most  of  them  the  crip- 
pling deformities  resulting  from  paralysis  were  of  a  degree  needing  imme- 
diate and  continuous  expert  orthopaedic,  neurological  and  nursing  care. 
The  certainty  that  the  hospitals  and  relief  agencies  which,  in  the  past,  have 
met  such  needs,  would  be  unprovided  for  the  great  increase  of  service  soon 
to  be  demanded,  and  the  probability  that  many  of  the  dependent  parents 
of  the  crippled  children  would  be  unfamiliar  with  the  facilities  available 
for  their  treatment  and  relief,  pointed  to  the  need  of  organized  efforts  for 
the  after  care  of  discharged  patients.  Representatives  of  orthopaedic  hos- 
pitals and  relief  agencies  were  invited  to  meet  on  August  7th.  Following 
this  informal  conference  there  was  formed  a  permanent  organization,  liber- 


37 

ally  assisted  to  the  extent  of  paying  the  expenses  of  a  central  directing  and 
ofifice  staff,  by  the  Rockefeller  Foundation.  From  this  time  on,  all  patients 
discharged  at  the  end  of  the  isolation  period  from  the  Department  of  Health 
or  other  hospitals  were,  at  the  same  time,  reported  to  the  central  office  of  the 
Permanent  Committee  on  After-Care  of  Infantile  Paralysis  Cases.  As  soon 
as  the  arrangements  were  perfected  by  which  each  case  was  assigned  to  the 
appropriate  district  agency,  every  case  was  visited,  and  assisted,  or  merely 
kept  under  observation  as  conditions  warranted. 

The  spirit  of  loyal  and  unselfish  co-operation  shown  by  the  great  num- 
ber of  agencies,  lay  and  medical,  which  have  now  created  a  well  managed 
organization  of  inestimable  value  to  the  city,  cannot  be  too  highly  praised. 
A  further  contribution  of  this  group  was  made  when  it  was  decided  in  Oc- 
tober that  the  constituent  societies  should  forego  their  individual  opportuni- 
ties to  obtain  financial  aid,  for  the  sake  of  having  a  single  appeal  made  to 
the  public  for  funds  to  support  their  joint  campangn  of  relief  and  treatment 
for  the  next  two  years. 

Committee  on  House  to  House  Visits  Organized. 

On  August  5th  the  Committee  on  House  to  House  Visits  was  invited 
to  carry  out  the  suggestion  of  the  scientists  above  referred  to.  The  follow- 
ing societies  were  represented,  and  by  their  liberality,  public  spirit  and  de- 
votion to  a  difficult  social  experiment  added  to  the  debt  the  city  already 
owed  them  for  notable  services  in  the  interest  of  public  health  in  the  past. 

Manhattan — 

New  York  Association  for  Improving  the  Condition  of  the  Poor. 

Charity  Organization  Society  of  New  York. 

Henry  Street  Settlement. 

United  Hebrew  Charities  of  New  York. 

University  Settlement. 

Brooklyn — 

Brooklyn  Association  for  Improving  the  Condition  of  the  Poor. 

United  Jewish  Aid  Society  of  Brooklyn. 

Brooklyn  Bureau  of  Charities. 

Brooklyn  Society  for  the  Aid  of  Crippled  Children. 

Meetings  were  held  on  August  7th,  8th  and  10th. 

The  following  report  was  submitted  on  September  22d  as  the  result  of 
the  work  accomplished  under  the  administrative  direction  of  the  Depart- 
ment of  Health,  with  32  field  nurses  contributed  by  the  co-operating  socie- 
ties. In  addition  to  the  special  inquiry  carried  on  by  the  nurses,  a  contri- 
bution of  services  for  the  distribution  of  circulars  and  leaflets  of  informa- 
tion was  made  by  the  Metropolitan,  Prudential  and  Home  Life  Insurance 
Companies  and  their  field  agents,  and  by  the  University  Settlement.  The 
last  named  contributed  24  workers,  2  hours  a  night,  and  2  nights  a  week : 

"  It  was   decided  to  designate  two  areas  over  which  to  work. 
The  first  included  the  area  between  Delancey  street,  Essex  street, 


38 

East  Houston  street  and  Ridge  street,  Borough  of  Manhattan.  The 
other  was  bounded  by  Irving  avenue,  Greene  avenue.  Central  avenue 
and  DeKalb  avenue.  Borough  of  Brooklyn.  It  was  decided  to  carry 
on  a  house  to  house  inspection  of  these  two  areas  for  the  purpose  of 
reporting  cases  of  poliomyelitis  found;  to  enforce  quarantine  where 
required ;  to  report  to  the  Department  of  Health  violations  of  quaran- 
tine; to  instruct  the  individual  families  regarding  proper  sanitation 
of  the  apartments  and  rooms,  under  which  was  included  proper 
cleaning  of  premises,  proper  care  of  foods,  proper  hygiene  in  rela- 
tion to  the  care  of  children ;  proper  disposal  of  garbage  and  waste 
material ;  proper  care  of  hallways,  areaways,,  yards  and  streets ; 
proper  water  supply,  and  the  distribution  of  literature  by  means  of 
which  a  certain  amount  of  personal  education  was  aimed  to  be  accom- 
plished by  the  nurse  detailed  to  the  work. 

"  In  order  to  carry  out  this  program  more  effectively  two  forms 
were  devised  for  general  use.  The  first  in  the  form  of  sheets  and 
intended  for  the  use  as  a  daily  record.  This  form  included  a  first 
page  on  which  appeared  the  address,  borough,  character  of  house 
visited,  and  the  general  sanitary  condition  of  the  house,  yard  and 
areaways.  Upon  this  page  was  also  entered  the  date  of  the  visit, 
the  location  of  the  apartment,  the  number  of  adults,  the  number  of 
children  from  0  to  5  years  of  age,  the  number  of  children  from  5  to 
15  years  of  age,  the  number  of  cats,  the  number  of  dogs,  and  infor- 
mation as  regards  infestation  of  rats  and  mice.  Upon  this  form  was 
also  entered  the  personal  instruction  given  by  the  nurse  to  each  and 
every  family.  This  was  entered  under  the  date  of  the  visit  and  was 
for  the  purpose  of  providing  the  nurse  with  a  record  to  which  she 
could  subsequently  refer  upon  succeeding  visits  to  the  same  premises. 
She  was  required  to  enter  the  results  jof  her  work  subsequently 
under  the  same  space  as  was  entered  the  original  visit  until  her  in- 
structions were  finally  complied  with.  When  instructions  were  com- 
plied with  it  was  required  to  enter  the  date  on  which  such  compliance 
took  place.  The  second  page  of  this  form  contained  the  same  in- 
formation as  above  described  with  the  exception  of  the  general  char- 
acteristics of  the  house. 

"  The  second  form  which  was  devised  for  general  use  was  a 
mailing  card.  Mailing  cards  were  numbered  and  each  nurse  was  pro- 
vided with  a  specified  number,  the  numbers  all  in  sequence  and 
entered  in  a  register  book  in  the  department.  It  was  easy  at  a 
moment's  notice  to  ascertain  the  number  of  reports  which  the  nurse 
had  sent  in  by  simply  asking  her  the  number  of  cards  which  still  re- 
mained in  her  possession.  These  cards  were  not  used  for  anything 
but  official  reporting  purposes.  Upon  this  card  was  entered  the 
name,  age  and  address  of  the  individual  family  inspected  and  the 
date  of  inspection.  The  personal  hazards  reported  were  noted  on 
this  card  where  the  case  was  one  of  suspected  poliomyelitis  but  any 
other  infectious  disease,  such  as  diphtheria,  scarlet  fever,  typhoid, 
etc.,  were  reported  in  by  the  nurse.  Other  illnesses  were  reported  as 
to  their  character  and  whether  or  not  they  were  suspected  as  regards 
poliomyelitis.  Cases  noted  '  charitable  '  were  also  reported  in  and 
turned  over  to  the  proper  societies  for  action.  Other  hazards  which 
were  reported  were  bad  housing  conditions,  unclean  tenements,  over- 
crowding, violations  of  the  food  laws,  dirty  streets,  cellars  and  yards, 


39 

garbage  and  litter,  disorderly  or  illegally  occupied  premises,  and 
other  nuisances.  Reports  coming  under  the  jurisdiction  of  the  Tene- 
ment House  Department  were  forwarded  immediately  through  official 
channels.  The  executive  officer  of  the  Department  of  Health,  in 
charge  of  this  work,  placed  himself  in  personal  communication  with 
the  Commissioner  of  the  Tenement  House  Department  in  order  to 
obtain  special  action  upon  these  complaints.  Complaints  involving 
the  Bureaus  of  the  Department  of  Health  were  immediately  for- 
warded to  the  appropriate  officer.  A  record  was  made  in  the  office 
of  the  House  to  House  Visiting  Committee  of  the  Department  of 
Health  as  regards  complaints  received,  who  from,  character  of  com- 
plaint, date,  and  to  whom  referred,  which  has  been  entered  in  the 
form  of  a  book  record. 

"  On  the  14th  day  of  August,  1916,  nurses  were  assigned  to  this 
work.  A  total  force  of  32  finally  concluded  their  work  on  the  20th 
day  of  September.  Each  nurse  was  assigned  to  a  specified  district 
in  the  above  described  areas.  She  was  required  to  visit  each  and 
every  house  in  her  district  daily.  All  nurses  were  required  to  visit 
the  Department  of  Health  each  Monday  at  9  A.  M.  in  order  to  report 
officially  the  results  of  their  work  during  the  week  and  were  required 
to  present  daily  notations  which  were  revised  by  the  executive  officer, 
and  personal  instructions  were  given  to  each  nurse. 

"  During  the  period  between  August  14th  and  September  20th, 
the  following  activities  of  these  nurses  in  the  various  boroughs  were 
recorded : 


"  Number  of  houses  visited '. 1,( 

"  Number  of  families  visited 10,348 

"  Number  of  houses  revisited 4,446 

"  Number  of  families  revisited 33,426 

"  Number  of  suspected  poliomyelitis  cases  reported 17 

"  Of  these,  the  actual  number  found  to  be  true  cases 
were  9,  of  which  4  had  been  previously  reported. 

"  Other  cases  of  illness 160 

"  Of  these  14  were  measles,  3  diphtheria,  17  whooping 

cough,    7    chronic   myelitis,    11    pneumonia,    15    recovered 

measles. 

"  Total    number    of    infectious    disease    cases    (other    than 

poliomyelitis)  found 67 

"  Cases  previously  reported  to  the  Department 26 

"  Found  to  be  '  No  Case  ' 67 


160 


"  One  is  struck  with  the  fact  that  so  few  cases  of  poliomyeHtis 
have  been  reported  by  these  nurses  and  of  those  reported,  so  few 
were  found  to  be  true  cases. 

"  Great  difficulty  was  found  in  the  earlier  visits  to  induce  jani- 
tors to  keep  stairs,  hallways,  yards  and  areaways  in  a  clean  and  sani- 
tary condition.  It  was  found  necessary  for  the  Department  to  use 
its  authority  in  many  instances,  if  only  to  oblige  the  individuals  in 
charge  of  houses  to  place  them  in  proper  sanitary  condition. 


40 

"  One  of  the  most  flagrant  violations  from  a  sanitary  standpoint 
seems  to  be  a  habit  of  throwing  garbage  and  rubbish  out  of  the  win- 
dows. In  spite  of  earnest  efforts  made  by  the  entire  force,  this  was 
only  remedied  to  an  exceedingly  insignificant  degree.  Another  point 
brought  out  was  the  fact  that  a  sufficient  quantity  of  water  is  not  sup- 
plied, especially  from  the  third  floor  up.  This  is  due  to  the  fact  that 
the  tanks  on  the  roofs  are  not  properly  cared  for;  the  janitors  do 
not  see  that  they  are  filled  at  the  proper  time.  A  large  number  of 
complaints  have  been  forwarded  regarding  this  violation. 

"  It  was  found  by  the  nurses  that  especial  care  was  exercised 
by  the  mothers  of  the  children  from  birth  to  2  years  of  age.  In 
other  words,  during  those  months  when  the  child  was  helpless  the 
mother  took  fairly  good  care  of  it.  As  soon  as  the  child  was  able  to 
take  care  of  itself,  to  a  certain  degree,  neglect  by  the  mother  fol- 
lowed. 

"  It  was  noted  throughout  the  districts  that  few  flies  have  been 
present  this  year.  These  are  usually  of  the  common  house  variety, 
green  flies  usually  infesting  street  carts  where  fruits  are  exposed. 
Few  green  flies  have  been  reported  in  the  house.  The  districts, 
however,  especially  Manhattan,  have  been  heavily  infested  with  rats 
and  mice.  Large  numbers  of  stray  cats  have  been  reported  and 
removed. 

"  All  nurses  detailed  to  this  work  reported  that  they  were  fairly 
well  received  in  a  large  percentage  of  instances.  Parents  accepted 
their  advances  in  the  light  of  education  and,  in  the  majority  of  cases, 
complied  with  their  requests.  They  understood  the  work  as  being 
directed  against  the  transmission  of  a  highly  contagious  disease  and 
most  nurses  who  were  detailed  to  this  work  expressed  satisfaction 
as  to  the  results,  from  a  general  sanitary  standpoint,  which  they  ob- 
tained. The  nurses  instructed  the  parent  how  to  care  for  the  chil- 
dren's noses  and  throats,  and  as  to  the  danger  of  contact. 

"  The  principal  sanitary  violations  remedied  were  the  dirty  per- 
sonal habits  of  children;  lack  of  bathing  of  children;  neglect  of 
toilets,  yards  and  cellars ;  improper  water  supply ;  improper  feeding 
of  children ;  improper  care  of  foods ;  improper  protection  from  flies  ; 
bad  housing,  bad  plumbing,  food  violations  as  regards  exposure ; 
uncovered  garbage  cans,  and  improper  disposal  of  garbage. 

"  An  analysis  of  the  report  as  regards  orders  complied  with  and 
orders  partially  complied  with,  shows  that  approximately  80%  of 
families  visited  complied  wholly  or  in  part  with  the  sanitary  instruc- 
tions of  the  nurses.  While  it  is  impossible  to  say  whether  or  not 
.this  experiment  was  effective  against  poliomyelitis,  it  can  be  stated 
confidently  that  it  was  of  great  value  from  a  sanitary  standpoint  of 
appreciable  value  from  an  educational  standpoint.  The  systematized 
visiting  of  houses,  continually,  for  a  certain  length  of  time  impressed 
upon  the  minds  of  the  inhabitants  of  these  districts  the  importance 
of  sanitation  in  the  proper  care  of  children.  These  ideas  will  be 
retained  for  a  greater  length  of  time  by  the  children  ranging  from 
10  to  15  years  of  age;  in  fact,  much  of  the  active  work  which  has 
been  accomplishel  was  through  the  children  of  this  age.  Results 
obtained  among  adults  were  largely  due  to  fear  of  authority  and  the 
force  of  the  department  and  not  to  voluntary  action  on  their  part." 


41 

So  far  as  serving  as  an  additional  reliable  means  of  limiting  the  spread 
of  the  epidemic  is  concerned,  it  cannot  be  claimed  that  the  results  justified 
the  labor  and  expense  of  the  procedure.  The  discovery  of  9  true  cases  (not 
previously  reported)  in  five  weeks,  by  32  nurses,  is  the  net  result  of  this 
study  from  the  point  of  view  of  control  of  poliomyelitis.  There  is  no  good 
reason  to  believe  that  these  9  cases  would  not  have  been  reported  at  a  later 
date,  but  these  cases  should  nevertheless  be  credited  to  the  survey  of  the 
limited  areas  visited. 

As  a  demonstration  of  the  value  of  personal  intensive  education  applied 
to  tenement  dwellers,  the  experiment  was  a  success,  and  measured  by  the 
conditions  found  in  the  last  days  of  the  visits  and  by  the  diminution  in  sani- 
tary violations  discovered,  it  is  fair  to  say  that  there  was  an  improvement 
of  80  per  cent,  over  conditions  first  observed.  Such  results  may  be  expected 
to  follow  any  such  special  effort,  but  permanent  improverhent  does  not 
necessarily  result.  At  the  beginning  of  an  epidemic,  the  widest  use  of 
house  to  house  visits  to  discover  cases  and  to  abate  nuisances  is  most  desir- 
able. Undoubtedly  the  results  would  have  been  more  striking  had  this 
study  been  undertaken  early  in  July. 

Decision  as  to  the  Opening  of  the  Public  Schools. 

On  August  8th  a  decision  was  reached  which  aroused  much  public 
comment  at  the  time  and  later. 

The  date  already  set  for  opening  the  public  and  parochial  schools  was 
September  11th.  The  records  of  previous  epidemics  in  this  country  and 
abroad  indicate  that  the  attendance  of  children  at  school  had  played  no  part 
in  the  spread  of  the  disease,  either  among  those  attending  school  or  in  the 
community  at  large.  The  unprecedented  virulence  and  extent  of  the  exist- 
ing epidemic,  and  unfamiliarity  with  the  disease,  has  engendered  in  the 
public  such  a  state  of  mind  that  concession  to  public  alarm  seemed  advis- 
able. All  phases  of  the  situation  were  thoroughly  discussed  by  the  Advisory 
Committee  on  Poliomyelitis,  and  the  question  submitted  by  mail  to  such 
members  of  the  Mayor's  Advisory  Committee  as  were  no  longer  in  the  City. 

It  was  thought  that  more  harm  would  come  to  the  majority  of  the  chil- 
dren of  the  city  from  a  prolonged  postponement  of  school  opening  than 
could  be  expected  from  possible  exposure  to  the  disease  under  school  con- 
ditions. In  view  of  the  probability  that  the  abatement  of  the  epidemic 
would  be  so  well  established  and  so  generally  recognized  by  the  public,  by 
September  25th,  and  in  view  of  the  improbability  of  the  attendance  at  school 
in  any  way  determining  a  recrudescence  of  the  disease  at  that  time  of  year, 
the  decision  was  given  to  the  Board  of  Education  as  follows : 

(August  15,  1916.) 

"  Unless  there  should  be  a  very  marked  and  unexpected  reduc- 
tion in  the  incidence  of  poHomyelitis  during  the  next  three  weeks, 
the  Department  of  Plealth  will  recommend  that  the  opening  of  the 
public  schools  be  postponed  at  least  until  September  25th,  and  that 


42 

the  exact  date  be  fixed  later  and  announced  to  the  pubHc  press  not 
less  than  two  weeks  in  advance.  Any  recommendations  of  the  De- 
partment of  Health  concerning  the  postponement  of  school  opening 
will  apply  only  to  such  schools  and  classes  as  are  attended  by  children 
of  sixteen  years  or  less.  Neither  the  schools,  which  admit  only 
students  over  sixteen,  nor  the  Training  Schools  for  Teachers  need 
have  their  opening  postponed  after  September  11th." 

(September  11,  1916.) 

"  Nothing  in  the  progress  of  the  epidemic  has  occurred  which 
would  justify  any  change  in  the  date  as  at  present  agreed  upon. 

"  The  continued  abatement  in  the  epidemic  indicates  that  there 
will  be  so  small  a  number  of  cases  of  poliomyelitis  by  September 
25th  that  no  further  postponement  of  the  school  opening  need  be 
considered." 

On  September  11th,  a  further  conference  was  held  and  final  approval 
was  given  to  the  decision  previously  reached. 

In  spite  of  the  protests  of  certain  alarmists,  whose  fears  got  the  better 
of  their  judgment,  the  schools  were  opened  on  September  25th  and  not 
only  was  there  no  increase  among  children  of  school  age  following  this, 
but  there  was  a  steady  decrease  in  the  number  of  cases  throughout  the  city, 
continuing  the  abatement  of  the  epidemic  which  had  by  that  time  become 
well  established,  as  can  be  seen  from  the  following  brief  statement  of  cases 
reported  for  the  five  weeks  from  September  10th  to  October  14th. 

Cases  of  poliomyelitis  in  children  6  to  16  years  of  age,  inclusive : 

Week.  Cases  Reported. 

Sept.    10-16  36 

Sept.    17-23  21 

(Schools  opened  Sept.  25.) 

Sept.  24-30  22 

Oct.  1-  7  21 

Oct.  8-14  10  ' 
Cases  of  all  ages : 

Sept.  10-16  252 

Sept.  17-23  156 

Sept.  24-30  142 

Oct.  1-  7  96 

Oct.  8-14  72 

When  the  schools  opened  certain  precautions  were  taken  to  avoid  the 
introduction  either  into  the  city  or,  particularly  into  the  schools,  of  any 
children  who  had  been  recent  residents  in  places  outside  the  city  where, 
perchance,  the  method  of  isolation  and  control  did  not  give  the  same  degree 
of  protection  which  was  required  in  New  York  City, 

Arrangements  were  perfected  to  provide  adequate  medical  supervision 
for  the  schools  on  the  opening  day,  the  procedure  being  as  follows : 

All  children  who  had  resided  in  New  York  City  for  a  period  of  at 
least  two  weeks  before  the  opening  of  school,  and  in  whose  families  no 


43 

case  of  poliomyelitis  had  been  reported  within  a  period  of  eight  weeks,  were 
allowed  to  enter  school  at  once.  Children  who  had  resided  out  of  town 
within  the  two  weeks  period  prior  to  the  opening  of  school  were  excluded 
from  school  attendance  until  the  two  weeks  residence  in  New  York  City 
had  been  completed,  unless  they  were  able  to  show  certificates  signed 
by  the  health  officers  of  the  towns  in  which  they  had  resided,  stating  that 
they  had  not  been  exposed  to  an  infectious  disease  and  that  they  were  in 
good  physical  condition. 

The  United  States  Public  Health  Service  records  of  the  incidence  of 
poliomyelitis  outside  of  New  York  City  were  consulted,  in  the  case  of  all 
children  who  were  excluded  because  they  had  resided  out  of  town  during 
the  two  weeks  period,  and  could  not  present  proper  health  certificates.  If 
the  town  wherein  a  child  had  resided  was  found  to  be  in  an  "  infected 
area  "  according  to  these  records,  the  child  was  required  to  remain  out  of 
school  until  completion  of  the  two  weeks  residence  in  this  city.  If  the 
town  in  question  was  found  to  be  in  an  "  uninfected  area,"  the  child  was 
readmitted  to  school  at  once. 

The  practical  carrying  out  of  this  program  meant  the  inspection  and 
supervision  of  over  nine  hundred  thousand  children  in  the  public  and  paro- 
chial schools  of  the  city.  The  inspection  of  all  these  children  was  practically 
completed  on  the  opening  day  of  school  and  it  was  found  necessary  to  exclude 
nineteen  thousand  children  from  school  attendance.  The  names  and  ad- 
dresses of  these  children,  with  the  place  of  former  residence  outside  New 
York  City,  were  referred  back  to  the  central  office  of  the  Department,  where 
they  were  investigated  and  the  decision  reached  as  to  whether  or  not  such 
children  should  be  readmitted  to  school. 

Owing  to  the  length  of  time  required  to  investigate  each  name  sep- 
arately, it  was  found  impractical  to  do  otherwise  than  to  exclude  from 
school  attendance  for  the  full  two  weeks  period  from  the  opening  of  school 
all  children  who  were  unable  to  present  proper  health  certificates. 

The  private  schools  of  the  city  opened  somewhat  later  and  at  varying 
intervals.  The  same  procedure,  however,  was  carried  out  with  relation  to 
the  children  entering  such  schools.  In  these  instances,  each  school  was 
notified  of  the  regulations  of  the  Department  and  required  to  report  to  the 
Department  of  Health  the  names  and  addresses  of  all  children  who  were 
unable  to  comply  with  the  regulations  in  question. 

It  is  of  interest  to  observe  that  since  the  opening  of  the  private  schools, 
only  one  case  of  poliomyelitis  has  occurred  among  children  attending  such 
schools  and,  in  this  instance,  no  secondary  infection  occurred.  In  the  public 
and  parochial  schools  the  number  of  cases  occurring  after  school  opened 
was  practically  negligible  and,  again,  after  careful  inquiry  it  was  determined 
that  no  secondary  cases  developed  as  a  result  of  infection  among  children 
of  school  age. 

The  opening  dates  of  schools,  academies  and  colleges  within  the  city, 
where  the  students  were  over  16  years  of  age,  were  not  altered  at  the  re- 


44 

quest  or  order  of  the  Board  of  Health,  and  no  cases  among  those  attending, 
either  students  or  teachers,  were  reported. 

Appeal  for  Funds  for  Braces. 

On  August  8th,  also,  was  sent  out  an  appeal  for  funds  for  the  purchase 
of  the  appliances  such  as  permanent  braces  which  many  of  the  children  were 
in  need  of  at  the  time  of  discharge.  Such  mechanical  devices  as  were 
ordered  by  the  surgeons  in  charge  of  the  Department  of  Health  hospitals 
for  the  patients'  treatment,  during  the  isolation  period,  were  provided  at 
city  expense,  as  were  medicines,  nursing  care,  etc. ;  but  for  the  permanent 
equipment  of  these  crippled  patients  with  orthopaedic  apparatus  it  was  not 
considered  that  the  city  should  be  charged.  In  response  to  this  need,  the 
public,  individually,  and  through  the  press,  made  generous  response,  so  that 
a  total  of  $44,752.03  was  received.  Such  part  of  this  as  was  not  expended 
when  the  Department  no  longer  had  this  problem  to  meet  was  turned  over 
to  the  general  fund  of  the  Permanent  Committee  on  After  Care. 

Due  acknowledgement  of  the  individual  contributions  was  made  by  the 
Department  of  Health,  day  by  day,  through  the  newspapers. 

Entomologist  Appointed. 

On  August  11th  an  important  temporary  addition  to  the  professional 
staff  of  the  Department  of  Health  was  made  in  the  person  of  Charles  T. 
Brues,  Assistant  Professor  of  Entomology  of  Harvard,  who  served  the  city 
for  two  months,  and  during  that  time  carried  out,  with  the  assistance  of  the 
officers  of  the  Public  Health  Service  and  various  members  of  the  stafif  of 
the  Department  of  Health,  investigations  in  the  field  of  possible  insect  trans- 
mission of  the  disease.  Although  the  results  of  his  study  were  inconclusive, 
as  have  been  all  previous  studies  in  this  direction,  the  report  (see  page 
136)  is  of  value  in  throwing  additional  light  on  certain  disputed  points  and 
in  eliminating  some  insects  from  further  consideration. 

Other  Important  Activities  at  this  Time., 

Following  special  orders,  issued  on  August  11th,  important  action  by 
the  Department  was  taken : 

(1)  Investigation  was  begun  of  all  cases  of  poliomyelitis  in  the  Bor- 
ough of  The  Bronx,  with  the  possibility  in  mind  that  transmission  might 
occur  through  milk.  The  results  are  reported  under  the  chapter  on  Epi- 
demiology. 

(2)  Janitors  were  held  responsible  for  observation  of  quarantine  regu- 
lations by  tenants,  and  thus  more  effective  observance  of  the  law  was 
obtained  from  this  date  forward,  according  to  the  daily  reports  of  field 
nurses  and  police. 

(3)  To  further  insure  universal  compliance  with  and  respect  for  the 
quarantine  regulations,  inspections  were  made  twice  daily  in  certain  parts 


45 

of  the  city,  to  detect  wilful  violators,  and  summonses  were  issued  where 
justified.  The  courts  gave  prompt  and  unequivocal  support  to  the  Depart- 
ment in  such  cases. 

Conference  of  State  and  Territorial  Health  Officers  at  Washing- 
ton, D.  C. 

On  August  17th  a  conference  of  State  and  Territorial  Health  Officers, 
with  the  United  States  Pubic  Health  Service  was  held  at  Washington,  D.  C, 
following  a  telegraphic  call  sent  on  August  9th,  as  follows : 

"  Under  authority  of  public  health  law  1902,  a  conference  of 
State  and  Territorial  Health  authorities  with  the  Public  Health 
Service  is  called  to  meet  at  10  A.  M.,  Thursday,  August  17th,  to 
consider  the  poliomyelitis  situation  and  bring  about  greater  uni- 
formity in  methods  of  control.  Representation  of  your  State  is 
urgently  requested.     Wire  the  name  of  your  delegate." 

The  Commissioner  of  Health  of  New  York  City  was  asked  to  attend 
and  report  upon  the  methods  employed  and  the  results  so  far  observed  in 
New  York  City. 

The  program  of  the  meeting  was  as  follows : 

"  Call  to  order  by  the  Surgeon-General. 
"  Remarks  by  the  Secretary  of  the  Treasury. 
"  The  poliomyelitis  situation  in  the  various  States. 
"  The  prevention  of  the  interstate  spread  of  poliomyelitis. 
"  The  research  problems  in  poliomyelitis. 
"  The  symptomatology  of  poliomyelitis. 
"  The  epidemiology  of  poliomyelitis. 
"  General  principles  of  control. 

"  The  relation  of  the  community  to  the  after-care  of  poliomye- 
litis patients." 

There  were  no  suggestions  offered  which  justified  any  change  in  the 
methods  of  control  adopted  in  New  York  City,  and  there  was  general  ap- 
proval of  the  efforts  made  to  check  the  spread  of  the  disease  within  the  city 
and  to  neighboring  states. 

Three  committees  were  appointed,  and  their  reports  as  well  as  a  com- 
plete record  of  the  transactions  of  the  conference  may  be  found  in  the  issues 
of  the  United  States  Public  Health  Reports,  Vol.  31,  Nos.  34,  35,  36. 

Dead  Dogs  and  Cats. 

August  19th.  The  great  number  of  cats  and  dogs  found  dead  upon 
the  streets  and  collected  by  the  American  Society  for  the  Prevention  of 
Cruelty  to  Animals  when  found  at  large  was  explained  at  this  time  on  in- 
quiry, not  by  the  presence  of  any  disease,  but  by  the  fear  of  householders, 
and  the  general  inclination  on  the  part  of  the  public  to  rid  their  premises  of 
vermin  and  pets. 


46 

Use  of  Immune  Serum  in  Treatment. 

From  the  early  weeks  of  the  epidemic  promising  therapeutic  procedures 
were  employed  under  carefully  controlled  conditions  in  the  Department  of 
Health  hospitals,  and  through  specially  trained  diagnosticians  in  the  patients' 
homes,  where  very  early  or  suitable  cases  were  found.  Among  these,  one 
which  had  much  to  recommend  it,  upon  theoretical  grounds,  was  the  use 
of  the  blood  serum  of  recovered  patients,  that  is  so-called  immune  serum, 
from  the  fact  that  a  person  who  has  recovered  from  the  disease,  so  far  as 
is  known,  does  not  again  acquire  the  disease  if  exposed,  and  from  the  fur- 
ther evidence  of  animal  experiments  that  the  blood  serum  contains  some 
immunizing  properties. 

Through  the  activities  of  physicians  and  surgeons,  many  former  pati- 
ents were  persuaded  to  make  the  personal  sacrifice  necessary  to  supply 
blood  for  the  treatment  of  the  patients  in  the  present  epidemic.  General 
publicity  brought  additional  offers,  and  private  funds  were  given  to  the 
Department  of  Health  to  reimburse  those  who  were  making  this  contribu- 
tion at  considerable  personal  expense. 

In  order  to  give  every  chance  for  the  most  comprehensive  study  of  this 
treatment,  a  citizens  committee  was  formed,  upon  the  initiative  of  one  par- 
ticularly public-spirited  man  who  had  already  made  his  own  contribution 
to  the  supply  of  immune  serum. 

On  August  22d  the  matter  took  definite  shape,  a  circular  letter  from 
the  committee,  a  letter  from  the  Department  of  Health,  and  an  illustration 
being  issued  to  people  who  were  known  to  have  had  poliomyelitis : 

Citizens  Committee  to  Obtain  Serum  for  Infantile  Paralysis. 

"  To  Those  Who  Have  Had  Infantile  Paralysis: 

For  the  purpose  of  co-operating  with  the  Department  of  Health  in  ob- 
taining serum  for  the  children  who  have  contracted  infantile  paralysis  in 
the  present  epidemic,  a  Citizens'  Committee  has  been  formed. 

The  serum  is  made  from  the  blood  of  those  who  have  had  the  disease, 
and  it  is  hoped,  and  the  Department  of  Health  has  urged,  that  as  many  as 
possible  of  the  boys,  girls,  men  and  women,  who  themselves  have  suffered 
from  the  disease,  and  who  do  not  weigh  less  than  70  pounds,  will  give  their 
blood  to  prevent  the  lifelong  sorrow  that  comes  from  it.  The  enclosed 
copy  of  a  letter  from  Dr.  Emerson,  the  Commissioner  of  Health  of  New 
York  City,  explains  the  attitude  of  the  City  Officials. 

The  blood  is  collected  by  means  of  a  fine  hollow  needle  thrust  into  a 
vein  at  the  bend  of  the  elbow,  and,  as  Dr.  Emerson  states  in  his  letter,  the 
collection  of  blood  is  practically  painless  and  causes  no  inconvenience.  It 
will  be  done  by  the  doctors  of  the  Department  of  Health.  Enclosed  here- 
with is  a  picture  which  shows  the  simple  way  in  which  the  blood  is  taken. 


47 

Any  public-spirited  persons  willing  to  give  their  blood  should  go  either  to 

The  JJ'illard  Parker  Hospital, 

16th  Street  and  Avenue  B  (Foot  of  East  I6th  St.), 

Borough  of  Manhattan, 
and  ask  for  Dr.  Abraham  Zingher,  zi'ho  zi'ill  be  there  betzveen 
9  and  4  o'clock,  and  on  Saturdays  betu'eoi  9  and  12  o'clock. 
or  to 

The  Brooklyn  Office  of  the  Department  of  Health 
Flatbush  Avenue  and  Fleet  Street, 

Borough  of  Brooklyn, 
and  ask  for  Dr.  Samuel  Panmsse,  z^Pio  zcill  be  there  betz^'een 
3  and  5  o'clock  including  Saturdays  and  Sundays. 

Those  who,  for  any  reason,  are  unable  to  go  to  those  hospitals,  either 
because  they  cannot  use  the  customary  means  of  conveyance,  or  cannot  go 
at  the  times  stated,  should  communicate  with  John  S.  Billings,  ]\I.D.,  Dep- 
ut}'  Commissioner  at  the  Department  of  Health,  139  Centre  Street,  Xew 
York  City  whose  telephone  number  is  6280  Franklin,  in  order  that  appoint- 
ments may  be  made  to  supply  transportation  to  the  hospital  or  for  doctors 
of  the  Department  to  visit  the  homes  of  such  persons.  The  Committee  has 
arranged  to  provide  the  Department  with  the  means  of  conveyance.  As 
the  blood  serum  is  sometimes  impaired  by  transportation,  those  giving  their 
blood  are  strongly  urged  when  possible  to  visit  one  of  the  hospitals.  The 
Department  of  Health  will  not  take  blood  from  any  persons  who  are  under 
twenty-one  years  of  age  without  the  consent  of  the  parents  or  guardian." 

(Signed;     Lewis  L.  Delafield,  Jr.,  Chairman. 


Public  Letter. 


"  One  of  the  most  promising  methods  now  being  tried  for  treat- 
ing the  little  victims  of  infantile  paralysis  consists  in  the  spinal  injec- 
tion of  blood  serum  obtained  from  persons  who  have  had  the  disease. 
At  the  present  time,  large  amounts  of  this  serum  are  urgently  re- 
quired. 

"  Among  the  residents  of  the  city,  there  are  many  hundreds  who 
have  had  infantile  paralysis  in  the  past,  and  who  are  therefore  in  a 
position  to  supply  the  serum  needed  to  treat  the  patients  now  in  the 
hospitals.  Your  suggestion  that  a  Citizens'  Committee  co-operate 
with  the  Department  of  Health  in  canvassing  the  cit}'  for  prospective 
blood  donors  and  in  arranging  the  various  incidental  details  is  a 
happy  one,  and  I  cordially  accept  the  aid  thus  proffered.  If  neces- 
sar}'.  the  Department  will  be  very  glad  to  detail  competent  physicians 
to  collect  blood  in  the  homes  of  such  donors. 

•■■'  The  procedure  by  which  the  blood  is  collected  is  practically 
painless  and  causes  no  inconvenience.  In  fact,  not  even  a  bandage  is 
required." 


48 


This  picture  shows  the  simple  method  used   for  extracting  blood   from   which 
to  make  serum  for  infantile  paralysis. 


49 

In  response  to  this  appeal,  and  through  the  assistance  provided  by  the 
committee,  considerable  amounts  of  blood  serum  were  obtained.  The  full 
report  as  to  the  result  of  the  use  of  such  immune  serum  is  included  under 
the  section  on  Treatment,  page  264. 

Extra  Services  for  the  Department  of  Health  Discontinued. 

On  September  3d  the  abatement  of  the  epidemic  justified  the  return 
to  their  regular  duties  of  some  of  the  special  police  squad  assigned  to  in- 
spection and  enforcement  of  quarantine,  where  patients  were  isolated  at 
their  homes.  At  the  end  of  two  weeks,  all  extra  police  officers  were  re- 
turned to  their  usual  duty.  By  this  time,  the  daily  reports  of  cases  had 
fallen  to  the  number  reported  in  the  first  week  in  July,  but  with  this  im- 
portant diiTerence  that  while  it  was  well  recognized  in  June  and  July  that 
many  unrecognized  and  unreported  true  cases  existed  throughout  the  city, 
now  only  30  per  cent,  to  40  per  cent,  of  the  cases  of  sickness  supposed  to  be 
poliomyelitis  were  found  by  the  diagnosticians  to  be  true  cases,  and  there- 
fore included  in  the  daily  report. 

On  September  9th  all  restrictions  were  removed  from  play  blocks, 
moving  picture  theatres,  carnivals,  etc. 

On  September  23d  the  services  of  some  of  the  employees  obtained 
through  the  emergency  appropriation  were  discontinued,  and  a  week  later 
it  was  found  possible  to  release  ail  the  temporary  force  engaged  in  field 
work.  The  peak  of  the  emergency  load,  from  the  hospital  point  of  view, 
was  reached  considerably  later  (6-8  weeks)  than  was  the  case  with  the 
field  work,  and  the  extra  nurses  in  the  department  hospitals  were  kept  until 
the  ward  service  fell  off,  after  all  transfers  from  private  hospitals  had  been 
accomplished  and  the  normal  census  of  patients  had  been  reached. 

On  September  27th  all  placards  were  removed  from  the  outside  of  pri- 
vate houses,  and  from  the  main  entrance  and  hall  of  tenement  and  apart- 
ment houses,  which  was  apparently  causing  some  hardship  to  the  owners 
of  vacant  apartments  offered  for  rent.  The  placarding  of  all  premises  was 
considerably  modified. 

On  October  4th  the  supervision  of  interstate  traffic  by  the  Public  Health 
Service  was  discontinued,  and  all  excluded  children  were  admitted  to  public 
and  parochial  schools. 

On  October  19th  the  Advisory  Committee  on  Poliomyelitis  held  its 
last  meeting  at  the  Department  and  recommended  that  the  Department  of 
Health  require  6  and  not  8  weeks  quarantine.  The  policy  of  hospitaliza- 
tion was  endorsed. 

Declaration   That  Imminent   Peril  No  Longer  Exists. 

On  October  31st  the  following  resolution  was  passed  by  the  Board  of 
Health : 

"  The  Board  of  Health  at  a  meeting  held  July  5,  1916,  issued  its 
declaration  that  great  and  imminent  peril  existed  to  the  public  health 


50 

of  the  people  of  the  City  of  New  York,  by  reason  of  an  outbreak  of 
poliomyelitis  (infantile  paralysis)  throughout  the  City  of  New  York, 
and 

"  Whereas,  The  Board  of  Health  having  taken  and  filed  among 
its  records  what  it  regards  as  sufficient  proof  to  authorize  the  declara- 
tion that  the  epidemic  due  to  the  prevalence  of  polimyelitis  (infantile 
paralysis)  has  modified  to  such  an  extent  that  the  great  and  imminent 
peril  to  the  public  health  no  longer  exists,  be  it,  therefore, 

"  Resolved,  That  the  Board  of  Health  hereby  declares  that  the 
great  and  imminent  peril  due  to  the  prevalence  of  the  epidemic  of 
poliomyelitis  (infantile  paralysis)  in  the  City  of  New  York,  is  no 
longer  deemed  to  exist." 

On  November  6th,  for  the  first  time  since  the  first  week  of  June,  no 
new  cases  or  deaths  from  poliomyelitis  were  reported  to  the  Department 
of  Health. 

On  November  28th  the  quarantine  period  of  six  weeks  was  re-estab- 
lished by  resolution  of  the  Board  of  Health. 

Circular  of  Information  Regarding  Procedure. 

The  procedure  in  force  during  the  epidemic  is  well  described  in  the 
following  circular 'of  information: 

Incubation  Period:  The  incubation  period  of  the  disease,  and  the 
quarantine  period  of  children  under  sixteen  years  of  age  who  have  been, 
but  no  longer  are,  exposed  to  infection,  has  been  set  at  fourteen  days. 

Quarantine:  In  all  families  where  a  case  of  poliomyelitis  has  occurred, 
all  the  children  under  sixteen  years  (except  those  who  have  had  the  disease) 
are  quarantined  in  the  home  until  two  weeks  after  the  termination  of  the 
case  by  death,  removal  or  recovery.  The  patient,  whether  at  home  or  in 
hospital,  is  quarantined  for  eight  weeks  from  the  date  of  onset  of  the  dis- 
ease.    No  case  in  hospital  may  return  home  until  quarantine  is  ended. 

Placards:  All  premises  where  a  case  of  poliomyelitis  occurs  are  pla- 
carded, the  only  exceptions  being  hotels  and  boarding  houses,  which  are 
not  placarded  provided  patient  is  at  once  removed  to  hospital,  the  room  or 
rooms  immediately  disinfected,  and  no  quarantined  children  remain  on  the 
premises.  In  private  houses,  one  placard  is  placed  on  the  street  wall  of 
the  house,  and  one  on  the  door  entering  room  the  patient  occupies.  In  apart- 
ment and  tenement  houses,  three  placards  are  posted — one  on  the  street 
wall,  one  on  the  wall  of  the  entrance  hall,  and  one  on  the  door  of  the  apart- 
ment.    All  placards  must  be  dated  and  initialed. 

Removal  to  Hospital:  No  case  may  be  left  at  home  unless  the  follow- 
ing conditions  are  complied  with : 

(a)  There  must  be  a  physician  in  daily  attendance. 

(b)  The  patient  must  have  a  special  attendant,  who  must  obey 
quarantine  regulations  and  must  not  do  any  housework,  marketing 
or  perform  any  household  duties  for  other  members  of  the  family. 


51 

He  or  she  can,  however,  leave  the  house  provided  the  necessary  pre- 
cautions as  to  personal  disinfection,  etc.,  are  observed,  but  should 
avoid  all  children. 

(c)  The  patient  and  the  attendant  must  have  a  room,  or  rooms, 
separate  from  the  rooms  of  others  in  the  family. 

(d)  All  the  windows  of  this  room  must  be  screened  and  all  files 
in  the  room  killed. 

(e)  The  family  must  have  a  separate  toilet  for  its  exclusive  use. 

(f)  Quarantine  regulations  must  be  strictly  obserAxd  by  the 
patient  and  the  other  children  of  the  family,  if  any.  When  the  disease 
occurs  in  the  premises  of  families  of  food  handlers,  the  emplo}TTient 
of  such  person  or  persons  at  this  occupation  is  forbidden,  unless  they 
occupy  entirely  separate  apartments,  for  a  period  of  two  weeks  after 
the  removal,  recover}^  or  death  of  the  patient. 

(g)  Disinfection  and  Renovation:  The  personal  and  bed  linen 
of  the  patient  must  be  properly  disinfected  and,  after  removal, 
recovery  or  death  of  the  patient,  complete  renovation  of  the  room  or 
rooms  occupied  by  the  patient  and  attendant  is  required. 

Duties  of  Inspectors: 

Cases  are  reported  by  physicians,  nurses,  social  workers  and  other  citi- 
zens, and  all  are  visited  at  once  by  inspectors,  even  those  reported  by  physi- 
cians with  request  that  they  be  admitted  to  hospital.  Attending  physicians 
to  Department  Hospitals  may  admit  cases  direct,  without  inspector's  visits. 

The  janitor  or  his  representative  must  be  seen  in  every  instance  and 
notified  that  he  or  she  will  be  held  personally  responsible  by  the  Department 
for  keeping  quarantined  children  in  the  family  premises,  and  seeing  that 
placards  are  not  removed  or  defaced. 

If  the  inspector  makes  or  confirms  the  diagnosis  of  pohomyelitis,  the 
Borough  Office  of  the  Department  is  notified  and  by  it  the  ambulance  is 
summoned,  if  removal  is  indicated.  In  every  case  the  inspector  leaves  the 
hospital  admission  slip,  properly  and  fully  filled  out.  When  case  is  left  at 
home,  inspector  must  give  full  instructions  to  family. 

All  cases  of  questionable  diagnosis  must  be  seen  at  once  in  consultation 
with  the  Borough  or  Chief  Diagnostician,  and  whenever  it  is  required,  spinal 
puncture  will  be  made  and  laboratory  report  submitted  by  the  staft  of  the 
Research  Laboratory.  Cases  with  positive  laboratory  findings  will  be  con- 
sidered as  poliomyehtis,  regardless  of  clinical  signs.  A  full  history  must 
be  recorded  on  a  special  card  (Form  316-V)  for  each  assignment  covered 
by  inspectors. 

Duties  of  Nurses: 

Nurses  will  visit  every  case  reported,  to  instruct  the  family  regarding 
quarantine,  and  every  other  family  in  the  house : 

(a.)   That  there  is  a  case  of  this  disease  in  the  house 
(bj    That  the  other  children  of  the  family  in-  which  the  disease 
has  occurred  will  be  quarantined,  and  that,  should  they  fail  to  observe 
quarantine,  that  fact  should  be  immediately  reported  to  the  Depart- 


52 

merit  of  Health,  when  steps  will  be  taken  to  enforce  quarantine  by  a 
summons  to  Court. 

(c)  Regarding  home  cleanliness,  personal  hygiene,  the  danger 
of  infection  by  flies,  and  other  general  measure  which  should  be 
taken  to  prevent  infection. 

(d)  To  report  at  once  to  the  Department  any  cases  of  suspicious 
illness  of  children,  or  any  cases  of  poliomyelitis,  especially  if  there  is 
no  physician  in  attendance. 

A  current  history  (Form  304-V)  must  be  kept  by  the  nurse  for  every 
case,  giving  dates  of  visits,  action  taken  and  date  and  mode  of  termination. 

Nurses  must  see  the  janitor  or  his  representative  on  first  visit,  and 
repeat  the  instructions  given  by  the  inspector. 

Patients  remaining  at  home  and  families  with  quarantined  children  are 
visited  daily  by  the  nurse  or  patrolman  for  the  maintenance  of  quarantine, 
and  oftener  if  necessary.  After  removal,  recovery  or  death  of  the  patient, 
nurses  issue  renovation  notices,  following  these  up  by  visits  until  complied 
with. 

Duties  of  Sanitary  Police: 

These  officers, visit  frequently- — daily,  if  necessary — quarantined  prem- 
ises, to  enforce  quarantine  of  patient  and  other  children  in  the  family,  and 
to  affix  or  replace  placards.  They  serve  summonses  when  quarantine  regu- 
lations are  violated  and  appear  in  Court. 

Ambulance  Surgeons: 

All  cases  ordered  removed  to  hospital  must  be  removed  by  the  ambu- 
lance surgeon  without  question,  with  the  following  exceptions,  in  each  of 
which  the  ambulance  surgeon  must  first  obtain  telephone  authorization  from 
the  Resident  Physician  of  his  hospital,  to  leave  the  case  at  home : 

(a)  When  removal  would  endanger  life  of  child  (bulbar  cases). 

(b)  When  family  physician  can  show  that  requirements  will  be 
met  at  once  (or  within  12  hours). 

Doubtful  and  mixed  infection  cases  must  be  removed  by  themselves  in 
a  separate  ambulance. 

In  every  case  ambulance  surgeons  must  leave  a  card  with  parents,  giv- 
ing name  and  address  of  hospital  to  which  patient  is  taken.  If  inspector 
has  not  left  admission  slip,  surgeon  must  make  out  same. 

Visitors  to  Hospitals: 

Each  case  may  be  visited  twice  during  its  stay  in  the  hopsital,  by  a 
parent  or  guardian.  If  child  is  critically  ill,  the  guardian  or  parent  will  be 
notified  and  will  be  permitted  to  visit  daily,  while  child  is  dangerously  ill. 
Information  relative  to  condition  is  given  out  at  the  Information  Desk  in 
each  hospital,  or  by  telephone  in  response  to  telephone  inquiry  from  the 
parent  or  guardian. 


53 

Certificates  for  Children  Leaving  the  City: 

The  Department  of  Health  of  New  York  City  does  not  require  certifi- 
cates of  anyone  leaving  or  entering  the  city.  It  issues  certificates  only  as 
a  convenience  and  aid  to  persons  leaving  the  city.  None  are  issued  to  per- 
sons passing  through  the  city. 

Such  certificates  state  that  the  persons  or  family  therein  named  have 
not  resided  in  a  house  where  a  case  of  poliomyelitis  has  occurred.  The 
applicant  must  sign  a  request  for  the  certificate.  They  are  refused  to  per- 
sons who  live  in  a  house  where  a  case  of  infantile  paralysis  has  occurred, 
or  who  present  symptoms  of  the  said  disease. 

The  certificates  are  good  only  until  midnight  of  the  following  day, 
except  when  issued  on  a  Saturday  or  on  the  day  preceding  a  holiday,  when 
they  are  good  until  midnight  of  the  second  following  day. 

Persons  Leaving  New  York  State:  Officers  of  the  U.  S.  Public  Health 
Service,  stationed  at  transportation  terminals,  require  the  above  certificates 
before  they  will  permit  children  under  15  years  of  age,  resident  in  New 
York  City,  traveling  to  points  outside  of  the  State  of  New  York,  to  leave 
the  city.  The  original  applicant  must  again  sign  the  certificate  in  the  pres- 
ence of  the  Federal  Health  Officer.  Federal  Health  Officers  do  not  require 
certificates  of  any  adults. 

Persons  Going  to  Points  Within  New  York  State:  Residents  of  New 
York  City,  adults  or  children,  traveling  to  points  within  New  York  State, 
who  present  certificates  of  good  health  from  their  family  physicians,  may 
also  obtain  the  above  certificates  from  the  Department  of  Health.  H  no 
physician's  certificate  of  good  health  is  presented,  applicants  will  be  exam- 
ined b}^  a  physician  and  their  freedom  from  symptoms  of  poliomyelitis 
certified ;  in  this  case,  all  children  must  be  brought  to  the  proper  office  of 
the  Department. 

Return  of  Cases  of  Poliomyelitis  to  New  York  City: 

Cases  of  poliomyelitis  occurring  in  residents  of  New  York  City  who 
are  temporarily  residing  outside  the  city,  and  developing  within  two  weeks 
of  the  time  of  leaving  the  city,  will  be  permitted  to  return,  provided  (a)  a 
private  conveyance  (private  car,  private  automobile,  carriage  or  ambulance) 
is  used,  and  (b)  the  patient  goes  direct  to  a  hospital  authorized  by  the  De- 
partment of  Health  to  care  for  cases  of  poliomyelitis. 

Cases  in  which  the  onset  of  the  disease  occurs  two  weeks  or  more  after 
leaving  the  city,  may  not  return  to  New  York  City  until  eight  weeks  from 
the  date  of  onset  of  the  disease.  But  in  special  cases,  where  proper  medical, 
surgical  and  nursing  care  is  not  obtainable,  patients  may  be  brought  back 
to  the  city  in  a  private  conveyance,  providing  they  go  directly  to  a  private 
room  in  a  private  hospital  authorized  by  the  Department  of  Health  to  receive 
cases  of  poliomyelitis. 


54 

Return  of  Children  Who  Have  Been  Exposed  to  Poliomyelitis  to   New 
York  City: 
Children  under  sixteen  outside  of  New  York  City  who  have  been  ex- 
posed to  infection  with  poHomyeHtis  within  two  weeks,  may  return  to  the 
city  under  the  following  conditions : 

They  must  come  by  private  conveyance  and  must  go  direct  to 
their  homes. 

Advance  notice  must  be  sent,  and  authorization  obtained,  by 
telephone,  by  the  local  Health  Officer.  Such  notice  must  give  the 
name  and  age  of  each  child,  together  with  the  identified  address, 
including  the  floor,  and  the  latest  date  of  exposure  to  infection,  and 
must  be  followed  immediately  by  a  written  notice. 

Such  children  will  be  promptly  visited  at  their  homes  by  a  rep- 
resentative of  the  Department  of  Health,  and  instructed  as  to  nature 
and  duration  of  quarantine.  They  must  not  leave  the  premises  until 
two  weeks  have  elapsed  from  the  date  of  last  exposure  to  infection. 

The  premises  are  not  placarded,  but  the  children  are  visited  at 
regular  intervals,  and  should  quarantine  be  violated  the  parents  or 
guardians  are  summoned  to  Court  and  fined. 

Important  Miscellaneous  Activities. 

Special  mention  is  due  to  certain  aspects  of  the  epidemic  and  of  the 
official  work  of  the  City  during  the  epidemic,  not  falling  logically  within 
the  scientific  treatment  of  the  subject  which  constitutes  the  chief  and  most 
valuable  part  of  this  report.     These  are : 

A.  The  co-operation  of  the  various  City  Departments. 

B.  The  legal  controversies  and  decisions  resulting  from  the 
enforcement  of  the  procedure  authorized  by  the  Board  of  Health. 

C.  Steps  in  procedure  by  the  Department  from  time  of  report  of 
a  case  until  its  recovery,  removal  or  death. 

D.  The  account  of  expenses  authorized  under  emergency  condi- 
tion existing. 

E.  Suggestions  as  to  the  causes  and  cures  for  the  disease.     ' 

A. 

From  the  beginning  of  the  epidemic,  generous  and  voluntary  assistance, 
was  given  to  the  Board  of  Health  and  the  Department  of  Health  by  the 
Mayor  and  his  commissioners.  From  the  following  departments  especially 
valuable  co-operative  service  was  received : 

Police  Department:  .  , 

Extra  efforts  to  enforce  compliance  with  all  City  ordinances 
bearing  upon  sanitrition  of  streets. 

Special  force  of  volunteer  cycle  policemen  assigned  to  Depart- 
•     ment  of  Health  to  enforce  quarantine. 

Support  of  the  Department  of  Health  in  obtaining  compliance 
with  the  unusual  restrictions  put  upon  public  gatherings. 

Record  of  all  removals  of  families  within  and  between  boroughs. 


The  card  used  to  record  all  cases  after  the  diagnosis  was  estabhshed  or 
confirmed  by  physicians  of  the  Department,  was  as  follows- 


£ 

UI 

>* 

2 

U] 

< 

0 

z 

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57 

Tenement  House  Department: 

Supplementary  and  extra  inspections  in  tenement  premises  where 
violations  were  fpund  or  cases  reported. 

Original  study  of  relationship  between  case  incidence  in  tene- 
ments and  the  number  of  families  per  tenement. 

Street  Cleaning  Department: 

Flushing  of  all  paved  streets  at  least  once  every  24  hours, 
throughout  the  congested  tenement  quarters  of  each  borough,  by 
assignment  of  extra  squads  for  night  work. 

Extra  collections  to  insure  prompt  removal  of  household  waste 
and  street  sweepings. 

Department  of  Licenses : 

Enforcement  of  restrictions  put  upon  places  of  public  assembly. 

Board  of  Education : 

Assistance  through  the  principals  and  teachers,  in  obtaining 
exclusion  of  children  at  the  beginning  of  the  school  year,  in  accord- 
ance with  requirements  of  the  Department  of  Health. 

Department  of  Plant  and  Structures : 

Providing  generous  addition  to  the  motor  passenger  service  when 
the  necessity  for  rapid  transportation  for  physicians  and  nurses 
became  acute. 

Civil  Service  Commission  and  Department  of  Finance  gave  the  Department 
instant  and  obliging  assistance  in  the  many  cases  of  unusual  demand 
it  was  forced  to  make  for  personal  service  and  the  use  of  emergency 
funds. 

B. 

Legal  Activities  of  the  Board  of  Health   of  the  Department  of 

Health  of  the  City  of  New  York  During  the 

Epidemic  of  Poliomyelitis. 

Pozvers,  Jurisdiction  and  Authority  of  the  Board  of  Health. 

The  legal  activities  growing  out  of  the  outbreak  of  poliomyelitis  in  the 
City  of  New  York  afforded  a  splendid  opportunity  for  considering  the 
powers  and  duties  of  the  Board  of  Health  and  the  Department  of  Health 
of  the  City  of  New  York  during  the  presence  of  a  serious  epidemic  of  dis- 
ease, which  necessitated  the  exercise  of  the  extraordinary  powers  vested  in 
the  Board  of  Health  to  act  in  such  an  emergency.  A  short  resume  of  the 
law  governmg  the  action  of  the  Board  and  the  more  interesting  and  im- 
portant questions  arising  as  a  result  of  its  enforcement  may  be  of  interest 
and  value  and  are,  therefore,  briefly  considered  in  this  report. 

The  various  statutory  provisions  under  which  the  Board  of  Health 
exists,  and  which  define  its  powers,  jurisdiction,  and  authority,  will  be 
found  in  Sections  1167  to  1325,  both  inclusive,  of  the  Greater  New  York 
Charter.  The  sections  which  particularly  enumerate  the  powers  of  the 
Board  are  Sections  1168,  1169,  1170,  1172  and  1178. 


58 

The  Board  of  Health,  by  virtue  of  the  provisions  of  Section  1172  of 
the  Greater  New  York  Charter,  is  authorized  and  empowered  to  adopt  the 
Sanitary  Code,  which  embraces  regulations  on  a  general  variety  of  subjects 
connected  with  the  public  health  and  is  a  permanent  code  of  health  laws 
covering  all  the  ordinary  contingencies  and  circumstances  which  require 
intervention  of  public  authority  for  the  security  of  life  and  health. 

The  Greater  New  York  Charter  makes  a  violation  of  the  Sanitary  Code 
a  misdemeanor,  and  the  punishment  for  a  misdemeanor  is  imprisonment  in 
the  penitentiary  or  county  jail  for  not  more  than  one  year,  or  a  fine  of  not 
more  than  five  hundred  dollars,  or  both.  Discretion,  however,  is  vested  in 
the  trial  court  as  to  the  degree  of  punishment  to  be  imposed  in  any  par- 
ticular case.  In  addition  to  the  criminal  penalty,  the  Charter  also  provides 
that  a  violation  of  the  said  Code  subjects  a  party  to  a  penalty  in  the  sum 
of  fifty  dollars  to  be  recovered  in  a  civil  action.  In  determining  to  what 
court  to  submit  a  violation,  the  Department  of  Health's  action  is  governed 
by  the  offense,  and  the  more  serious  violations  are  submitted  to  the  criminal 
courts  for  determination. 

The  provisions  of  the  Sanitary  Code  which  provide  securities  against 
the  spread  of  infectious  diseases,  including  poliomyelitis,  will  be  found  in 
Article  7,  Section  86  to  103,  inclusive,  thereof. 

To  supplement  the  provisions  of  the  Sanitary  Code  and  to  prescribe,  in 
more  detail,  the  duties  and  obligations  imposed  by  the  provisions  thereof, 
the  Board  of  Health  is  empowered  to  adopt  regulations  which  have  the 
force  and  effect  of  law  in  the  City  of  New  York.  Section  1262  of  the 
Greater  New  York  Charter  also  makes  a  violation  of  such  regulations  a 
misdemeanor. 

It  is  perhaps  unnecessary  to  recall  the  fact  that  the  powers  vested  in 
the  Board  of  Health  to  adopt  the  provisions  of  the  Sanitary  Code  have  been 
repeatedly  sustained  by  the  highest  courts  of  this  State. 

The  sections  of  the  Sanitary  Code  hereinbefore  referred  to  were  in 
force  and  effect  prior  to  the  outbreak  of  the  epidemic  poHomyelitis  in  the 
City  of  New  York,  and  no  change  or  alteration  was  made  during  its  exist- 
ence. However,  in  addition  to  the  provisions  of  the  Sanitary  Code,  the 
Board  of  Health  at  a  meeting  on  July  5,  1916,  in  accordance  with  the  pro- 
visions of  Section  1178  of  the  Greater  New  York  Charter,  declared  that 
great  and  imminent  peril  to  the  public  health  existed,  due  to  the  outbreak  of 
poliomyelitis  in  the  City  of  New  York. 

In  addition  to  such  declaration,  the  Board  adopted  regulations  govern- 
ing the  quarantine,  removal,  care  and  treatment  of  persons  suffering  from 
anterior  poliomyelitis  and  procedures  to  be  followed  by  the  Department  of 
Health  in  the  enforcement  of  such  regulations. 

The  above  briefly  indicates  the  provisions  of  law  in  force,  during  the 
existence  of  the  epidemic  of  poliomyelitis,  and  it  provided  the  basis  upon 
which  the  Department  of  Health  might  act  in  all  emergencies. 


59 

Administrative  Action. 

The  Department  of  Health  is  the  administrative  branch  of  the  Board 
of  Health  and  is  charged  with  the  duty  of  enforcing  all  laws  apphcable  in 
the  City  of  New  York,  including  the  Charter  of  the  City  of  New  York, 
the  Sanitary  Code,  the  Regulations  and  the'  Orders  of  the  Board  of  Health 
of  the  Department  of  Health  of  the  City  of  New  York.  The  Board  of 
Health,  in  adopting  the  Sanitary  Code  and  the  Regulations  particularly 
relating  to  Poliomyelitis,  provided  a  legal  basis  for  the  action  of  the  De- 
partment of  Health.  Under  the  direction  of  the  Commissioner  of  Health, 
who  is  the  executive  officer  of  the  Department  of  Health,  these  provisions 
of  law  were  enforced  in  a  reasonable  and  uniform  manner  during  the  preva- 
lence of  the  epidemic. 

The  attitude  of  the  pubHc,  generally,  was  in  accord  with  the  action 
taken  by  the  Board  and  it  voluntarily  complied  with  the  conditions  imposed 
by  the  Code  and  the  Regulations,  although  in  man,y  instances  it  necessitated 
personal  self-sacrifice.  In  a  few  instances — considering  the  number  of 
cases  existing — it  became  necessary,  however,  for  the  Department  of  Health 
to  take  drastic  action,  by  forcibly  removing  cases  to  the  hospitals  or  by 
prosecuting  persons  who  neglected  or  refused  to  comply  with  the  conditions 
imposed  by  the  Sanitary  Code  and  the  Regulations.  A  short  resume  of  the 
facts  upon  which  these  prosecutions  were  based  wih  be  considered  in  this 
report. 

The  legal  work  performed  in  behalf  of  the  Department  was  not,  how- 
ever, limited  to  cases  arising  out  of  the  enforcement  of  the  laws  relating 
to  poliomyelitis.  The  Department,  in  co-operation  with  other  departments 
under  the  jurisdiction  of  the  Mayor  of  the  City  of  New  York,  instituted  a 
"  clean  up  crusade,"  which  had  for  its  purpose  the  general  sanitary  improve-  . 
ment  of  the  City.  The  departments  principally  interested,  besides  the  De- 
partment of  Health,  were:  the  Street  Cleaning  Department,  the  Tenement 
House  Department  and  the  Police  Department. 

The  action  taken  was  predicated  upon  the  various  provisions  of  the 
Sanitary  Code  relating  to  sanitation  generally  and  the  care  and  preservation 
of  food  and  drink.  As  above  indicated,  a  violation  of  the  provisions  of  the 
said  Code  is  a  misdemeanor. 

As  a  result  of  the  crusade,  a  large  number  of  prosecutions  were  insti- 
tuted in  the  criminal  courts.  The  courts  co-operated  with  the  City  officials 
to  the  fullest  extent,  and  in  all  cases  where  the  offense  charged  was  sus- 
tained by  sufficient  evidence,  substantial  fines  were  imposed.  As  a  result 
of  the  action  taken,  the  general  sanitary  conditions  throughout  the  City 
were  greatly  improved  and  the  sale  of  foodstuffs  on  the  streets  were  effect- 
ively regulated  and  controlled. 

One  other  feature  of  the  legal  work  performed  was  the  prosecution  of 
unscrupulous  persons  engaged  in  the  despicable  practice  of  selling  worth- 
less preparations  as  preventions  and  cures  for  poliomyelitis  to  the  gullible 


60 

public.  It  is  a  well-known  fact  that  on  all  occasions  of  great  public  anxiety 
or  peril,  ignorant  and  conscienceless  individuals  take  advantage  of  the  con- 
dition existing  and  commit  acts  which  warrant  the  severest  punishment. 
These  medicine  fakirs  were  particularly  active  during  the  epidemic,  and  the 
efforts  of  the  Department  were  centered  on  bringing  them  to  justice.  Fortu- 
nately, the  action  taken  by  the  Department  was  immediate  and  drastic  and 
the  conviction  of  six  individuals  was  obtained  and  a  number  of  others  forced 
to  go  out  of  business.  The  circumstances  surrounding  this  particular  class 
of  prosecutions  are  interesting,  and  the  facts  of  a  few  cases  instituted  will 
be  briefly  dealt  with  later. 

Criminal  Actions  Instituted  During  the  Epidemic. 

(Actions  instituted  in  the  Supreme  Court.) 
A  most  interesting  case  arose  out  of  the  action  of  the  Department  in 
removing  from  a  private  dwelling  to  the  hospital  a  child  suffering  from  polio- 
myelitis, contrary  to  the  wishes  of  the  parents,  and  because  of  their  failure  to 
conform  with  the  requirements  of  the  Quarantine  Regulations  adopted  by 
the  Board  of  Health.  The  parents  of  the  child  applied  to  the  Supreme 
Court,  Kings  County,  for  a  Writ  of  Habeas  Corpus  to  compel  the  Depart- 
ment to  return  the  child  to  the  custody  of  its  parents.  The  facts  of  the 
case  are  briefly  as  follows : 

Robert  Anderson,  residing  at  180  New  York  Avenue,  Jamaica, 
Borough  of  Queens,  City  of  New  York,  was  reported  to  the  Depart- 
ment of  Health  by  an  attending  physician,  as  suffering  from  poliomye- 
litis. This  diagnosis  was  verified  by  the  District  Diagnostician  of  the 
Department  of  Health.  Subsequently,  the  parents  called  in  another 
practicing  physician,  who  pronounced  the  child  to  be  suffering  with 
malaria  and  not  with  poliomyelitis.  Upon  being  informed  of  this 
fact,  the  Department  of  Health  had  the  child  examined  by  the  Chief 
Diagnostician  of  the  Department  and  the  Borough  Diagnostician  of 
the  Borough  of  Queens.  They  confirmed  the  original  diagnosis  and 
determined  that  the  child  was  ill  with  poliomyelitis.  The  parents 
also  procured  the  services  of  another  physician,  who  confirmed  the 
diagnosis  of  the  previous  physician  employed  by  the  parents,  and 
held  that  the  child  was  not  suffering  with  poliomyelitis.  The  parents, 
in  spite  of  repeated  warnings,  instructions,  and  notifications  of  the 
Department  of  Health,  both  written  and  verbal,  refused  and  neglected 
to  isolate  the  child  and  to  take  the  ordinary  necessary  precautions  to 
prevent  the  infection  of  other  children  in  the  family  and  in  the  neigh- 
borhood. 

Great  publicity  was  given  to  the  case  in  the  daily  newspapers, 
and  exaggerated  reports  as  to  the  action  and  requirements  of  the 
Department  of  Health  were  published. 

The  facts  and  circumstances  of  the  case,  showing  as  they  did  an 
utter  disregard  of  the  rights  of  the  public  to  protection  against  the 
spread  of  the  disease,  necessitated  the  Department  in  taking  drastic 
action  and  forcibly  removing  the  child  to  a  contagious  disease  hos- 
pital. Acting  under  orders  of  the  Commissioner  of  Health,  in 
accordance  with  the  provisions  of  Section  97  of  the  Sanitary  Code, 


61 

a  copy  of  which  is  hereinafter  set  forth,  the  child  was  removed  to  the 
Queensboro  Hospital. 

The  parents  thereafter  made  the  application  to  the  Supreme 
Court  for  the  writ  of  habeas  corpus.  The  case  occupied  the  atten- 
tion of  the  Court  for  four  days,  during  which  time  medical  ex- 
pert testimony  was  submitted  in  behalf  of  both  sides.  The  De- 
partment of  Health,  in  its  behalf,  submitted  the  testimony  of  several 
physicians  in  its  employ,  who,  by  virtue  of  their  training  and  experi- 
ence, had  an  intimate  knowledge  of  all  the  symptoms  of  the  disease, 
as  well  as  the  testimony  of  two  eminent  physicians  not  officially  con- 
nected with  the  Department,  which  testimony  was  all  to  the  effect  that 
the  child  was  suffering  from  poliomyelitis  in  the  convalescent  stage  of 
the  disease.  In  addition  to  the  expert  testimony  submitted,  the  testi- 
mony of  nurses  and  other  employees,  tending  to  prove  the  breach  of 
the  quarantine  regulations  was  given.  The  petitioner  submitted  evi- 
dence of  two  physicians,  which  was  to  the  effect  that  the  child  was  not 
suffering  from  the  disease.  The  testimony  of  the  mother  and  others, 
in  regard  to  the  facts  and  circumstances  surrounding  the  removal  of 
the  child  as  well  as  the  conditions  existing  prior  to  such  removal,  was 
also  submitted. 

The  attorneys  for  the  petitioner  contended :  that  the  Department 
of  Health  exceeded  its  powers  in  acting  in  the  manner  it  did ;  that 
the  child  was  not  suffering  from  poliomyelitis ;  that  there  had  been 
no  breach  of  the  quarantine  regulations,  and  that  the  regulations  were 
unreasonable  and  arbitrary.  The  Corporation  Counsel  contended: 
that  the  Board  acted  within  its  powers  in  adopting  Section  97  of  the 
Sanitary  Code  and  the  regulations  of  the  Board  of  Health  governing 
the  quarantine,  care  and  treatment  of  persons  suffering  with  polio- 
myelitis ;  that  the  child  had  poliomyelitis  at  the  time  of  his  removal 
by  the  Department,  acting  in  accordance  with  the  provisions  of  Sec- 
tion 97  of  the  said  Code,  and  that  there  was  a  violation  of  such  regula- 
tions, justifying  the  removal  of  the  child  to  the  hospital. 

On  motion  of  the  Corporation  Counsel,  the  Court  dismissed  the 
writ  and  remanded  the  child  to  the  custody  of  the  Superintendent 
of  Queensboro  Hospital  for  Contagious  Diseases  of  the  Department 
of  Health. 

It  might  be  mentioned  here  that  the  petitioner  waived  the  pro- 
duction of  the  child  in  the  court,  so  that  he  was  not  present  during 
the  procedure  before  the  court. 

Section  97  of  the  Sanitary  Code,  authorizing  the  removal  of  the 
child  is  as  follows  : 

"  Removal  of  Persons  Affected  zvith  Any  Infections  Disease 
Authorised. — Whenever  an  inspector  of  the  Department  of  Health 
shall  report  in  writing  that  any  person  affected  with  any  infectious 
disease,  under  such  circumstances  that  the  continuance  of  such  person 
in  the  place  where  he  or  she  may  be  is  dangerous  to  the  lives  or 
health  of  other  persons  residing  in  the  neighborhood,  the  Sanitary 
Superintendent,  an  Assistant  Sanitary  Superintendent,  or  the  Director 
of  the  Bureau  of  Infectious  Diseases,  of  the  said  Department,  upon 
the  report  of  a  medical  inspector  of  the  said  Department  may  cause 
the  removal  of  such  person  to  a  hospital  designated  by  the  Board  of 
Health." 


62 

Mr.  Justice  Garretson,  in  dismissing  the  Writ,  rendered  an  oral 
opinion,  sustaining  the  powers  of  the  Board  of  Health  to  act  under 
such  circumstances.  Brief  extracts  of  this  opinion  are  herewith  set 
forth : 

"  The  Court  (orally)  :  I  find  that  the  Board  of  Health  acted 
within  its  powers,  so  far  as  this  case  is  concerned,  in  a  public  duty 
which  it  had  to  perform,  not  for  the  welfare  of  the  child  alone, 
although,  of  course,  that  never  ought  to  be  lost  sight  of.  The  welfare 
of  the  particular  patient  and  the  natural  affection  of  his  relatives  are 
things  that  ought  never  to  be  lost  sight  of,  but  when  there  is  a  preva- 
lence in  the  community  of  a  noxious  or  contagious  communicable  dis- 
ease, such  as  is  shown  in  this  case  to  have  existed,  it  is  the  imperative 
duty  of  the  Board  of  Health  to  act,  and  the  Board  is  given  broad 
general  discretion  to  act  for  the  benefit  of  the  community  at  large 
and  the  public,  whose  rights,  in  such  health  matters,  are  paramount, 
and  to  which,  under  certain  given  circumstances  the  rights  of  private 
individuals  mUst  yield.  The  Board  undertook  to  perform  what  they 
deemed  to  be  their  duty  they  were  entirely  within  their  powers,  and 
I  believe  the  facts  of  the  case  justified  them. 

"  I  am  also  prepared  to  hold,  on  the  testimony  in  this  case,  that 
this  child  had  poliomyelitis.  I  do  not  personally  know  that  it  had  it 
— perhaps  it  did  not,  but  taking  all  the  testimony,  beginning  with  the 
expressions  of  opinion  that  were  made  at  the  beginning  of  the  history 
of  the  child's  case,  and  coming  down  to  the  time  this  writ  was  sued 
out,  and  down  to  the  present  time,  the  testimony  preponderates  in 
favor  of  the  Board  of  Health  and  necessarily  compels  the  conclusion 
that  this  child  had  poliomyelitis  at  the  time  the  quarantine  was  estab- 
lished. How  grave  and  serious  it  was  I  do  not  know.  It  may  have 
been  a  very  slight  case ;  I  hope  it  was  an  exceedingly  slight  case. 
But  I  think  the  evidence  justifies  and  compels  me  to  that  conclusion. 

"  The  quarantine  was  established.  The  establishment  of  the 
quarantine  was  a  matter  within  the  discretion  of  the  Board  of  Health. 
The  duty  of  the  Board  of  Health  as  conservators  of  the  health  and 
well  being  of  the  community  at  large,  is  to  take  charge  and  set  apart 
from  the  rest  of  the  community,  cases  of  infectious  or  contagious  or 
communicable  diseases.  That  is  within  their  particular  powers.  They 
are  not  bound  to  do  that  in  all  cases.  They  may  do  it  in  the  exercise 
of  their  judgment.  It  is  not  alone  a  matter  of  right,  but  is  also  a 
matter  for  the  exercise  of  their  sound  discretion.  They  may  allow 
the  patient,  under  conditions  which  will,  in  their  judgment,  be  equally 
efficacious  to  the  taking  of  the  patient  into  a  hospital,  to  remain  in  a 
private  house,  under  certain  rules  and  restrictions,  with  certain  warn- 
ings, placards,  and  so  forth.  They  are  not  bound,  after  once  having 
established  a  quarantine  to  allow  that  quarantine  to  continue,  nor  do 
the  patient  or  custodians  or  guardians  of  the  patient  acquire,  by  the 
establishment  of  the  quarantine,  an  absolute  right  to  have  it  con- 
tinued. Its  continuance  rests  in  the  sound  discretion  of  the  Board  of 
Health.  The  Board  must  act  in  a  reasonable  manner,  because,  while 
these  powers  are  broad  and  extensive  and  are,  seemingly,  almost 
arbitrary,  there  are  certain  rights  which  the  people  have  and  which 
the  individual  has,  upon  which  they  and  he  may  insist.  Those  rights 
are  that  there  shall  be  reasonable  grounds,  at  least,  for  the  exercise  of 
these  plenary  powers  of  the  Board  of  Health.     *     *     * 


63 

"  Private  property  cannot  be  taken  and  personal  liberty  cannot 
be  restrained,  even  by  Boards  of  Health,  except  where  the  facts  in  a 
particular  case  justify  the  finding  that  the  Board  or  its  authorized 
agents  were  acting  upon  facts  which  make  their  action  reasonable 
and  proper  and  necessary,  in  carrying  out  the  paramount  purpose 
of  the  existence  of  the  Board. 

'■'  This  good  lady,  the  mother,  tender,  affectionate,  cleaving  to  her 
child,  wanting  to  have  it  at  home  was  uncertain  what  she  ought  to 
do.  She  was  inspired  in  the  first  instance  by  a  sense  of  public  dut}^, 
which  told  her  that  she  ought  to  report  the  case  or  have  it  reported 
when  the  first  doctor  came  in.  She  was  evidently  confused  by  the 
conflicting  opinions  of  the  medical  gentlemen  with  whom  she  later 
came  into  contact.  At  first  she  seems  not  to  have  objected  particu- 
larly to  the  quarantine.  Later  on,  when  at  least  two  doctors.  Dr. 
Smith  and  Dr.  Flynn,  gave  their  opinions,  which  were  in  conflict 
with  the  opinions  of  the  other  physicians,  she  thought  that  she  might 
relax  the  duty  which  was  imposed  upon  her  by  the  quarantine  regu- 
lations, and  she  did  so.  The  safeguards  which  are  recognized  as 
necessary  to  be  thrown  around  a  case  of  this  particular  disease, 
were  taken  down  and  removed  by  her,  largely  upon  the  opinion  of 
the  two  doctors  to  whom  I  have  referred.  Dr.  Smith  and  Dr.  Flynn, 
and  naturally  enough,  too,  because  their  opinions  were  in  the  line  of 
her  motherly  affection  and  her  motherly  instinct,  and  in  the  line  also 
of  her  personal  desires  as  to  herself,  her  children  and  others,  that 
she  should  be  free  to  receive  anj^body  into  the  house  and  go  into  other 
houses  and  out  upon  the  street,  as  though  there  were  no  communicable 
disease  affecting  this  child. 

"  The  Board  of  Health,  under  those  circumstances,  had  a  right  to 
take  the  child,  and  do  with  it  what  it  was  permitted,  under  the  law, 
to  do  in  the  first  instance,  but  which,  in  the  exercise  of  its  discretion, 
it  had  not  done.  The  Board  of  Health  took  the  child  from  the 
custody  of  its  parents  and  put  it  into  the  particular  hospital  which 
was  set  apart  for  that  purpose.     ^     ^     ^ 

"  Nothing  is  to  be  found  here  except  these  matters  of  fact  which 
I  have  stated  to  you,  which  are  based  upon  the  evidence  presented, 
and  which  matters  of  fact  found  by  me  are  applied  to  the  law  of 
the  case.  The  Court  does  not  decide,  as  a  matter  of  fact,  anything 
outside  the  testimony  in  this  particular  case,  and  particularly  not 
upon  the  scientific  or  medical  aspect  of  the  disease.  It  may  be  shown 
in  the  future  that  all  this  theory  upon  which  it  is  sought  to  be  demon- 
strated that  poliomyelitis  is  a  communicable  disease,  is  wrong.  The 
views  of  the  medical  fraternity,  as  at  present  expressed  as  the  con- 
sensus of  opinion  of  a  majority,  may  be  modified  or  may  be  con- 
firmed, so  it  seems  to  me  that  such  a  determination  on  the  part  of  this 
court  would  be  just  as  futile  as  for  the  court  to  determine  who  was 
the  author  of  certain  literature,  the  authorship  of  which  has  been  dis- 
puted for  several  centuries.  This  court  will  not  undertake  to  deter- 
mine any  such  question. 

"■  But  this  all  leads  to  the  conclusion,  and  I  so  find,  that  the 
Board  of  Health  acted  within  its  powers  in  this  particular  case  as  the 
case  is  shown  to  the  Court ;  that  the  quarantine  was  disregarded ;  and 
that  the  action  of  the  Board  of  Health  in  taking  charge  of  this  child 
and  secluding  it  was  entirely  within  its  powers,  within  its  rights  and 
within  its  authoritv.     *     *     * " 


64 

One  other  case  was  instituted  in  the  Supreme  Court,  involving  the 
placarding  of  the  outside  door  of  a  large  apartment  house.  An  application 
for  an  injunction  pendente  lite  against  the  Board  of  Health  and  the  Com- 
missioner of  Health,  to  require  them  to  remove  from  and  not  replace  on 
the  outside  main  entrance  of  an  apartment  house  premises  certain  placards 
announcing  the  presence  of  poliomyelitis  in  the  apartment  house,  was  made. 
The  peculiar  facts  and  circumstances  surrounding  the  particular  case  in 
question  resulted  in  the  Court  granting  the  motion  and  ordering  the  Depart- 
ment to  remove  the  placards  in  question. 

(Actions  instituted  in  the  lower  courts.) 

The  prosecutions  instituted  against  individuals  for  selling  alleged  medic- 
inal preparations  for  the  cure,  prevention  and  relief  of  poliomyelitis  are  as 
follows : 

Joseph  Frook  was  charged  with  a  violation  of  Section  118  of  the 
Sanitary  Code,  in  that  he  made  false  and  misleading  representations  as  to 
the  kind,  quality,  purpose  and  effect  of  a  certain  alleged  drug  or  medicinal 
preparation,  offered  and  intended  as  a  medicine,  to  the  public.  The  alleged 
drug  or  medicine  in  question  consisted  of  a  bag  containing  cedar  wood  shav- 
ings, to  be  worn  around  the  neck  of  the  child  affected  with  poliomyelitis. 
Frook  was  the  manufacturer  of  this  bag  containing  the  cedar  wood  shavings 
and  claimed  that  it  would  protect  the  child  from  death  and  would  also  pre- 
vent germs,  insects,  etc.,  from  attacking  the  victim.  Frook  was  also  charged 
with  a  violation  of  Section  421  of  the  Penal  Code,  in  that  he  published  false 
and  misleading  advertisements  in  the  daily  newspapers.  He  was  convicted 
and  sentenced  to  thirty  days  in  jail  and  to  pay  a  fine  of  two  hundred  and 
fifty  dollars. 

James  T.  Manchester  was  charged  with  a  violation  of  Section  118  of 
the  Sanitary  Code,  in  that  he  made  false  and  misleading  representations  as 
to  the  kind,  quality,  purpose  and  effect  of  a  certain  alleged  drug  or  medicinal 
preparation,  to  wit :  "  Sol,"  offered  and  intended  as  a  medicine,  to  the  public. 
The  alleged  drug  or  medicine  in  question  consisted  of  a  bottle  containing 
essentially  capsicin,  sassafras  and  alcohol.  Manchester  was  the  manu- 
facturer or  this  alleged  drug  or  medicine,  and  claimed  the  preparation  would 
cure  infantile  paralysis,  consumption,  rheumatism  and  other  diseases.  He 
was  convicted  and  sentenced  to  thirty  days  in  the  City  Prison. 

Charles  Stiriz  was  charged  with  a  violation  of  Section  118  of  the  Sani- 
tary Code,  in  that  he  made  false  and  misleading  representations  as  to  thq 
kind,  quaHty,  purpose  and  effect  of  a  certain  alleged  drug  or  medicinal 
preparation,  to  wit :  "  Surmacyl,"  offered  and  intended  as  a  medicine,  to  the 
public.  The  alleged  drug  or  medicine  in  question  consisted  essentially  of 
malt  and  salicylic  acid.  Stiriz  was  the  manufacturer  of  this  alleged  drug 
or  medicine  and  claimed  the  preparation  would  cure  infantile  paralysis. 
He  was  convicted  and  sentenced  to  thirty  days  in  the  City  Prison. 


65 

Charles  Smith,  -who  claims  to  be  one  hundred  and  three  years  old,  was 
charged  with  a  violation  of  Section  118  of  the  Sanitary  Code,  in  that  he 
made  false  and  misleading  representations  as  to  the  kind,  quality,  purpose 
and  effect  of  a  certain  alleged  drug  or  medicinal  preparation,  to  wit :  "  Pro- 
tector to  prevent  and  relieve  Infantile  Paralysis,"  offered  and  intended  as 
a  medicine  to  the  public.  Charles  Smith  was  the  manufacturer  of  this 
alleged  drug  or  medicine  and  claimed  the  preparation  would  relieve,  prevent 
and  cure  infantile  paralysis.     The  court  fined  Smith  five  hundred  dollars. 

Gertrude  Zabriskie,  for  a  similar  ofifense  as  that  committed  by  Charles 
Smith,  was  fine  three  hundred  dollars. 

In  addition  to  the  aforesaid  violations,  a  number  of  retail  pharmacists 
were  prosecuted  and  convictions  obtained  for  the  substitution  of  ingredients 
in  prescriptions.  Fines  ranging  up  to  one  hundred  dollars  were  imposed  by 
the  courts. 

It  might  be  well  to  mention  that  all  actions  instituted  in  behalf  of  the 
Department,  involving  this  vicious  type  of  violation  of  the  law,  were  success- 
fully prosecuted  and  very  severe  penalties  imposed  by  the  courts. 

The  following  is  a  summary  of  the  number  of  actions  instituted  in  the 
criminal  courts,  and  their  dispositions,  involving  violations  of  the  Quaran- 
tine Regulations : 


Interfering 
With  Officer. 


\'iolation  of 
Quarantine. 


Removing 

Placards 

From  Doors. 


Fined    

Discharged    

Sentence   suspended    

Total   prosecutions    .... 
Amount  of  fines  imposed... 


3 
$30  00 


6 
2 
2 

10 
$18  00 


The  following  is  a  summary  showing  the  number  of  actions,  arising 
out  of  the  activities  of  the  Department  of  Health  during  the  "clean-up" 
campaign,  instituted  in  the  Criminal  Courts : 


Department  of  Health.  Total. 

Bureau  of  Food  and  Drugs 1.356 

Sanitary    Bureau    573 

Sanitary   Police    2>2)7 

Total    2.266 


Sent-    Prison 
ence  Sus-  Sent-       Dis-        Amount 
Fined,     pended.      ence.    missed,    of  Fines. 


1.135 

194 

275 

188 

279 

28 

25 

S3,057  00 

09 

1,271  00 

30 

599  00 

410 


164       $4,927  00 


The  following  is  a  summary  of  the  criminal  actions  instituted  by  the 
Bureau  of  Food  and  Drugs  against  persons  charged  with  violating  the  pro- 
visions of  the  Sanitary  Code  relating  to  the  sale  of  drugs  and  medicines: 


66 


Guilty, 

Pending     Amount 
Total.    Fined.  Sentence.  Prison.    Waiting    of  Fines. 

Sentence. 


Number  of  actions  instituted  for 
false  and  misleading  repre- 
sentations as  to  purpose  and 
effect  of  drugs  and  medicines.  8  3  13  1  $850  00 

Substitution  of  ingredients  in 
prescriptions    2  2  . .  . .  . .  200  00 


Total    10  5 1 3 1       $1,050  00 

c. 

Action  by  the  Department  From  the  Time  of  Report  of  Case  Until 

„  .  its  Recovery,  Removal  or  Death. 

Reporting — 

Article  VII.,  Sanitary  Code,  Sections  86  and  87. 

Sec.  86.  Duty  of  persons  in  charge  of  hospitals  and  of  physi- 
cians to  report  infectious  diseases. 

Sec.  87.  Duty  of  every  person  to  report  persons  affected  with 
an  infectious  disease. 

Isolation — 

Article'  VII.,  Sanitary  Code,  Section  89. 

Sec.  89.     It  shall  be  the  duty  of  every  physician  immediately 

.  -upon  discovering  a  person  affected  v^ith  an   infectious   disease,  to 

secure  such  isolation  of  such  person  or  to  take  such  other  action  as 
is  or  may  be  required  by  the  regulations  of  the  Department  of 
Health. 

Form  for  Reporting  (395  V) — 

Postal  cards  for  reporting  cases  of  infectious  diseases  are  fur- 
nished, upon  request,  to  hospitals,  dispensaries,  and  physicians,  free 
of  charge.  ' 

This  card  contains  a  list,  alphabetically  arranged,  of  the  diseases 

to  be' reported,  also  several  paragraphs  of  information  pertinent  to 

assistance  rendered  by  the  Department. 

The  principal  items  to  be  reported  of  a  case  of  infectious  disease 
are  printed  on  card  so  that  full  details  desired  are  indicated. 

Day  List — 

On  receipt  of  a  report,  by  card  or  otherwise,  each  morning,  a 
list  of  the  cases,  classified  by  boroughs  and  by  districts  in  a  borough, 
is  made  by  the  stenographic  bureau. 

This  list,  together  with  envelopes  addressed  and  postage  prepaid, 
is  sent  by  departmental  messenger  to  the  printer.  Immediately  after 
printing,  the  list  is  placed  in  the  envelopes  and  at  once  sent  by  printer 
to  Post  Office. 

Public,  parochial,  day  schools  of  various  character,  social  wel- 

fare,  charitable  institutions,  libraries  public  officials  and  others  receive 

this  list  daily,  except  Sundays  and  holidays. 

The  list  is  complete  for  the  entire  City  and  contains  the  name, 
age,  address,  and  disease  of  each  case  reported  for  the  previous  24 
hours.  Exception  being  only  on  days  following  Sundays  and  holi- 
days, when  the  list  is  for  the  previous  48  hours.  During  the  height 
of  the  epidemic,  no  exception  was  allowed. 


Press  Copy — 

During  an  unusual  incidence  of  epidemic  disease,  advance  in- 
formation for  publicity  is  prepared  as  follows  :  The  cases  are  reported 
to  executive  office  by  telephone,  the  list  is  then  sent  to  stenographic 
bureau,  which  mimeographs  the  necessary  number  of  copies  required. 
250  copies  have  been  made  within  one  hour,  making  it  possible  to  give 
information  as  early  as  10  o'clock  each  morning. 

Diagnosis — 

On  receipt  of  a  report  of  a  case  by  telephone,  postal,  or  personal 
complaint,  the  case  is  at  once  referred  to  a  district  diagnostician  for 
confirmation  of  diagnosis.  If  a  true  case,  the  premises  are  placarded, 
and  if  it  is  practicable  to  leave  the  patient  at  the  home,  the  family 
are  instructed  regarding  regulations,  and  the  epidemiological  history 
card  is  made  out. 

If  conditions  of  home  and  family  are  such  that  the  regulations 
cannot  be  complied  with  and  the  case  is  a  true  one,  the  diagnostician 
orders  the  removal  of  the  patient  to  the  department  hospital. 

Should  a  consultation  be  required,  the  diagnostician  confers  with 
either  the  nearest  district  diagnostician,  the  borough  diagnostician  or 
the  chief  diagnostician. 

Special  cases  or  cases  in  dispute  are  always  referred  to  the  Chief 
Diagnostician,  who  considers  the  case  until  final  disposition. 

Home  Quarantine — 

The  establishment  of  quarantine  in  the  home  is  by  the  district 
nurse ;  she,  having  received  the  assignment  from  the  branch  office, 
visits  the  home,  sees  the  patient,  gives  the  family  the  necessary  in- 
structions regarding  departmental  regulation,  excludes  from  school 
teachers  and  pupils  in  the  family,  placards  if  same  has  not  been  done, 
makes  out  history  card  and  notes  from  date  of  next  visit. 

Revisits  are  made  as  the  necessities  of  the  case  demand.  In  cases 
appearing  to  require  careful  supervision  revisits  are  made  daily  or 
oftener.     In  others,  at  irregular  intervals. 

Police  Inspection  of  Quarantine — 

In  order  to  maintain  a  strict  supervision  of  home  cases,  the  police 
(particularly  of  the  Sanitary'  Squad)  are  required  to  visit  the  home 
and  see  that  quarantine  is  being  obsen,-ed.  The  assignment  is  on_  a 
special  card  giving  full  instructions  to  the  patrolman,  and  after  visit- 
ing, the  report,  is  returned,  the  facts  as  found  being  entered  on  rear 
of  card  b3'  officer. 

Violations  of  Quarantine — 

Violations  of  quarantine  occurring,  and  such  being  detected,  a 
nurse  visits  the  premises  at  once  and  informs  the  family  and  warns 
them  not  to  repeat  under  pain  of  removal  to  hospital  of  patient.  The 
family  physician  is  also  informed  and  asked  to  aid  in  carrying  out 
regulations.  Where  it  is  thought  that  a  uniformed  patrolman  will 
have  more  influence  with  the  family,  one  is  sent  in  place  of  the  nurse 
to  inform  and  warn  the  family.  Continued  comphance  not  being 
obtained,  the  private  physician  is  informed,  a  district  diagnostician 
visits  home,  confirms  the  diagnosis,  and  if  true  poliomyelitis,  directs 
remcrv^al  of  patient  to  hospital.    The  ambulance  responds  to  such  call 


accompanied  by  surgeon,  nurse  and  patrolman,  and  removes  patient. 
The  district  nurse  calls  and  issues  instructions  regarding  renovation. 
Revisit  is  made  later  to  see  that  same  is  performed. 

Termination  of  Case — 

On  recovery,  removal  or  death  of  patient,  the  nurse  visits 
premises,  directs  disinfection  and  instructs  family  regarding  renova- 
tion. Such  being  complied  with,  the  placard  is  removed  by  the  nurse, 
and  quarantine  is  lifted.  Teachers  and  children  who  were  exposed 
are  excluded  from  school  for  an  additional  two  weeks  except  such  as 
have  had  the  disease,  who  may  at  once  re-enter  school.  At  expira- 
tion of  the  two  weeks  the  nurse  revisits  and  issues  necessary  school 
certificates. 

Teachers  and  pupils  who  may  have  availed  themselves  of  the 
special  privilege  of  a  change  of  address  are  now  permitted  to  return 
to  their  home  and  are  given  a  permit  to  attend  school  from  home 
address. 

Renovation  (a)  Voluntary;  (b)  Board  Order — 

On  recovery,  removal,  or  death  of  patient  the  nurse  issues  in- 
structions regarding  cleaning,  repapering  and  repainting  on  a  card 
"  voluntary  "  renovation  order.  This  order  not  being  complied  with, 
a  report  is  made  which  is  forwarded  to  the  Board  of  Health,  which 
issues  an  order  on  the  owner  directing  compliance  with  same.  If 
such  is  not  complied  with  within  a  reasonable  time  and  after  warning, 
a  summons  to  court  is  then  directed  and  the  case  placed  in  the  hands 
of  the  Magistrate  for  action. 

Records — 

Branch  Office: 

The  branch  office  makes  a  tally  card  of  case  for  assignment  and 
revisiting.  When  nurse  returns  white  history  card,  the  two  are  filed 
in  special  file  on  date  of  next  visit.  On  day  of  visit  the  history  card 
is  taken  by  district  nurse  and  tally  card  left  as  check.  Return  of 
history  card  by  nurse  after  revisiting,  the  two  cards  are  again  filed  at 
date  of  next  contemplated  visit.  On  completion  of  case,  tally  is 
removed.  History  card  is  supervised  and  if  complete  is  forwarded  to 
Borough  Office. 

Statistical  tabulations  are  made  weekly  and  forwarded  to  execu- 
tive office  of  Bureau. 

Special  reports  or  complaints  regarding  a  case  are  investigated, 
and  facts  are  subject  of  report  to  executive  office. 

Epi  demiology — 

Diagnostician  on  visiting  a  case  makes  out  an  epidemiological 
(blue)  card  and,  when  data  is  complete,  forwards  same  to  Division 
of  Epidemiology. 

From  the  data  furnished  by  the  various  offices,  this  division  pre- 
pares pin  maps,  charts,  curves,  statistical  tables  and  forwards  such 
reports  as  may  be  pertinent  or  desired  from  various  sources. 

Disposal  of  the  Dead — 

The  body  of  a  person  dying  of  the  disease  must  be  promptly 
enclosed  in  a  coffin  which  must  be  permanently  sealed,  and  the 
funeral  must  be  private. 


69 


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71 


Daily  Press  Report. 


From  the  Department  of  Health 

aty  of  New  York 


OFFICIAL 


To  the  Editor: 

A  very  large  part  of  the  work  of  the  Department  of  Health  depends  for  its  success  on  the  co-operation  of  an 
enlightened  public,  and  this,  in  turn,  depends  almost  entirely  on  the  amount  of  space  accorded  to  health  articles  by 
the  newspapers. 

If,  when  this  reaches  your  office,  your  men  are  out  on  stories  and  you  desire  further  information,  we  shall 
be  glad  to  answer  your  inquiries  over  the  telephone.     Please  ask  for 

The  Bureau  of  public  health  education 

DEPARTMENT  OF  HEALTH 
t2w  *F%tNKiJN  139  Centre  Street,  New  York 


PRESS    BULLETIN__<rjZsr.. 
Issued  (Date)  -Se^,  12> 


RELEASE    ^^^^^.^^^/^'^ 


New 
Cases. 


Dropped 
as  no      Total 
Cases.     Cases. 


Discharged 
from 
Total        Hospital, 
Deaths.    Deaths.     Recovered. 


Manhattan 
Bronx  . . . . 
Brooklyn  . 
Queens  . . . 
Richmond 


36 
13 
27 
15 
1 


1,912 
424 

4,157 
944 
276 


443 

95 

966 

257 

49 


4 
0 
27 
1 
2 


Total 92 

Total  Cases  in  Hospital... 
Department  Hospitals    . . . . 

Other  City  Hospitals 

Private   Hospitals    

Swinburne  Island 

Vacancies    . . , 

Cases  Removed  

Manhattan    

Bronx   

Brooklyn   

Queens    

Richmond   


7,713 


25 


1,810 


34 


3,924 

2,474 

660 

720 

70 

358 

71 

27 

12 

22 

9 

1 


Certificates. 


Certificates  Certificates 

Certificates      Issued       Certificates      Refused 
Issued.        to  Date.        Refused.       to  Date. 


Manhattan 
Bronx  . . . . 
Brooklyn  . 
Queens  . . . 
Richmond 


Name. 


700 
193 
941 
205 

24 

2,063 


34,007 

15,066 

45,538 

9,160 

1,411 

105,182 


172 

39 

190 

4 
2 


407 


New  Cases  and  Deaths  by  Boroughs. 
Age.  Address  by  Street  and  Borough 


Here  followed  the  list  of  new  cases  and  deaths,  arranged  alphabeti- 
cally, by  boroughs: 


72 


D. 


Emergency  Expenses  for  Personal  Service  and  Supplies  Authorized 
BY  THE  Mayor,  July  5,  1916. 

The  fallowing  tables  show  the  number  of  the  extra  employees  und&r 
classified  headings  on  the  payrolls  of  the  Department  for  each  week  of  the 
epidemic,  from  July  8th  until  September  30th.  On  this  date  the  service  of 
a  large  number  of  employees  was  terminated,  but  during  the  months  of 
October  and  November  a  lesser  force  was  retained  in  the  hospital  service 
for  the  after-care  of  the  convalescing  patients. 

Positions  Occupied   Temporarily  During  the  Epidemic  of  Poliomyelitis- 
July  to  September,  1916. 


Positions. 


Weeks  Ending. 


lO  -H  -rt 


Months 
Ending. 


^         o      „ 


i-ii-i>-iH^<;<;<;<t;t/)(/3wi/)c/20ZP 

Automobile 

Engineman -   9        10        11        11        12        14  16  13  11  7  7  6      

Bacteriologist 3555455555555633 

Clerics 3          9        12        13        15        21  21  20  18  16  16  11      

Domestics 19       48     104     100     138     156     185  213  237  250  253  259  261  194      ..       .. 

Entomologist 1          1  1  1  1  1  1  1      

Helpers 5          5          5          5        12  10  11  14  14  14  14  12      15      15 

Hospital  Physician       1          1          1          2          2          5          6  5  5  5  6  7  7  4.... 

Internes 10        22        23        34        40        34        29  31  34  35  40  28  31  26      .  . 

Laboratory 

Assistant. 3          3          3          34  4  4  3  3  3  2  334 

Masseur 5  5  5  5  5        4 

Medical  Inspector       3        72        74       81        80       80       80  76  76  75  53  53  53  1      .  .      .  . 

Nurses 68      159      194     214     255      337      381  403  422  433  430  419  404  172      ..       .. 

Orderlies 1          3          9        19       25        28  28  29  27  26  24  23  14      .  .      .  . 

Telephone 

Operator 1          1          1          1          1          2  1  1  1  1  1  1      

Type.  Copyist 2  2  3  2  3  3      

Total 104     321     432     477     571     679     768  816  860  886  862  845  827  437     25    22 


The  actual  amount  of  money  expended  for  the  payment  of  salaries  of 
these  incumbents  is  set  forth  in  the  following  table : 

Medical  Inspectors $15,951  61 

Nurses     76,867  03 

Clerks    2,703  07 

Chauffeurs    2,519  10 

Telephone  Operators    148  76 

Typewriting  Copyists    384  88 

Bacteriologists    2,422  52 

Laboratory  Assistants 843  02 

Helpers   2,509  13 

Entomologist    ' 600  00 

Hospital  Physician   1,713  23 


72 

Domestic     17,671  81 

Orderly   3,492  20 

Interne 2,253  81 

Masseurs     1,435  27 

Increases  in  salary 17,490  83 

Medical  Editor   300  00 

$149,306  27 

In  addition  to  the  above,  personal  service  was  furnished  to  other  City  Hospi- 
tals, over  and  above  their  regular  force,  at  the  following  cost : 

Xurses $1,228  80 

Attendants    826  99 

S2,055  79 

Total  Personal  Service $151,362  06 

Cost  of  Supplies.  Egitiptueiit.  Materials  and  Serz'icc — 

The  following  table  shows  by  classes,  the  amount  actually  expended  on 
poliomyelitis  activities  by  the  Department  for  everything  outside  of  personal 
service  and  treatment  of  cases  in  private  hospitals  : 

Stipplies — 

Food    $30,549  61 

Office     3  60 

jMedical  and  Surgical 1,893  54 

Laundry  and  Cleaning 326  96 

Refrigerating 618  10 

^lotor  Vehicle  215  38 

General  Plant 3.549  19 

Equipment — 

Office    $687  83 

Household 29,794  26 

Medical  and  Surgical 2,595  82 

Wearing  Apparel    10,986  60 

General    Plant 4,578  42 

Motor  \'ehicles  and  Equipment 3,652  64 

Materials    1.329  23 


74 

Service — 

General  Repairs   $2,133  07 

Motor  Vehicle  Repairs 1,135  02 

Hire  of  Automobiles 1,711  53 

Telephone 1,499  63 

Telegraph  201  89 

Supper  Money 525  45 

General  Plant  Service 70  45 

$98,058  22 

In  addition  to  the  above,  contract  and  open  market  order  re- 
serves have  been  established,  as  a  further  offset  to  the 
amount  spent  from  the  tax  levy  appropriation.  This 
amount  cannot  be  classified  at  present,  but  should  be 
considered  in  total,  as  an  additional  cost  of 24,922  80 

Total  Cost  of  Supplies,  etc $122,981  02 

Summary  of  Cost — 

Personal   service $151,362  06 

Supplies,  Equipment,  etc 122,981  02 

Treatment  of  cases  in  private  hospitals. .  .  .  42,903  59 


Total   $317,246  67 

As  a  point  of  interest,  several  articles  are  listed  which  were  purchased 
unusual   quantities   made   necessary   by   the   extraordinary   number   of 
patients  treated  in  the  hospitals  of  the  Department : 


m 


2306  Children's  cribs 
33600  Bird's  Eye  Cotton  Diapers 
7428  Crib  Sheets 
7512  Bed  Sheets 
8208  Children's  Nightgowns 
211  Tanks  Oxygen 
26  Bales  Cotton  Batting 

Transportation  Service. 

Under  usual  conditions  the  Department  is  supplied  with  four  or  five 
cars  daily.  This  service  was  entirely  inadequate  during  the  epidemic,  and  it 
was  necessary  to  have  on  immediate  call  twenty  cars  daily.  Through  the 
co-operation  of  the  Commissioner  of  Plant  and  Structures  the  Municipal 
Garage  furnished  the  Department  with  ten  cars  every  day.  it  being  under- 


75 

stood  that  this  Department  would  supply  the  chauffeurs  to  man  these  cars. 
Even  this  arrangement  was  insufficient,  and  automobiles  had  to  be  hired  to 
the  extent  of  $1,711.53. 

E. 

Suggestions  as  to  the  Causes  and  Cures  for  the  Disease. 

It  may  not  add  to  the  sum  of  scientific  data  to  quote  the  suggestions 
received  by  the  Department  of  Health  as  to  the  cause  and  means  of  curing 
or  preventing  poliomyelitis ;  but  as  a  record  of  human  interest  the  letters 
sent  from  all  over  this  country  and  from  many  foreign  lands  present  a 
picture  which  it  is  well  for  health  officers  to  bear  in  mind.  One  hardly 
knows  whether  to  laugh  at  the  fantasies  or  weep  over  the  ignorance  and 
superstition  exhibited. 

Two  hundred  and  thirty  suggestions  as  to  the  causes  of  the  disease  were 
received,  the  largest  number  of  authors  (80)  attributing  the  existing 
calamity  to  foods.  Ice  cream,  soft  drinks,  candy  and  summer  fruits  were 
generally  accused,  cereals  and  canned  foods  coming  second  in  favor.  All 
varieties  of  nuisances  were  accused  (40),  including  smells,  poisonous  gases 
from  the  European  war  reaching  here  as  the  earth  turns  around,  sewers, 
rubbish  bags,  automobile  smoke,  animals  (wild  and  domestic),  from  the 
horse  and  cat  to  the  man-eating  shark  and  game  birds.  Personal  contact, 
from  the  obvious  to  the  impossible,  was  described  by  many  as  the  proved 
cause  of  the  disease,  the  public  wet-wash  laundry  being  particularly  unpopu- 
lar. Atmospheric  conditions,  "  moisty  air  laden  with  coal  gas  and  gasoline," 
"  a  condition  similar  to  '  Bermuda  High  '  permeates  the  young  child  through 
the  pores,  reducing  blood  pressure,"  etc.  All  variety  of  insect  pests,  even 
including  the  tarantula,  which  was  supposed  to  inject  the  virus  into  bananas 
shipped  to  New  York  City,  were  pointed  out  as  obvious  causes.  Destruction 
of  flies,  which  may  live  on  poliomyelitis  virus,  was  supposed  to  be  the  reason 
for  increased  incidence.  The  crusader  against  tobacco  was  convinced  that 
the  disease  expressed  the  result  of  defects  inherited  from  nicotine-soaked 
parents. 

A  few  gems  of  description  deserve  special  mention.  A  doctor  of 
optometry  from  Vancouver,  B.  C,  attributes  the  disease  to  the  "  disruption 
and  destruction  of  the  brain  cells  by  the  ultra  violet  rays  of  the  sun ;  certain 
conditions  of  the  eyes  permitting  of  this  pathological  occurrence,  the 
chemical  action  of  these  violent  rays  causing  the  development  of  a  virus  and 
bacillus,  a  failure  of  the  circulation  in  the  brain  and  spinal  column  to  remove 
decomposed  matter  permitting  germination  and  interrupts  proper  function- 
ing, hence  the  partial  or  total  paralysis." 

A  "  High  Priest  of  Iris  "  from  Londonderry,  Ireland,  assures  us  that 
"  Fine  hydrogen  from  the  earth  is  incarnated  into  the  body,  the  paralysis 
resulting  from  the  hydronizing  of  the  parts  affected." 


76 

A  well-wisher  writes  from  San  Francisco  to  demand  the  suppression  of 
all  electrical  companies.  "  The  increasing  amount  of  radio  calls  and  wire- 
less electricity  in  the  air  gives  off  vibrations  which  pass  through  children's 
bodies,  act  on  delicate  tissues  and  minute  capillaries  which  press  on  nerves 
preventing  nourishment,  thereby  causing  paralysis." 

Pollen  of  plants,  subluxated  vertebrae,  maggots  in  the  colon,  tickling  of 
children,  are  suggested  by  a  number  of  writers. 

"  The  cause  may  be  linked  to  the  use  of  the  automobile  which  by  their 
unclean  fatty  refuse  give  rise  near  foul  water  to  a  venomous  putrefaction, 
which  might  offer  elements  of  life  to  the  '  plagues  '  spread.  It  goes  to 
children  particularly  because  of  the  fatty  elements  of  the  infective  injections 
and  the  easy  assimilation  to  the  adipose  parts  of  the  child  body.  It  is  in 
relation  to  the  increased  proclivities  of  adaptation  to  the  field  of  contagion 
that  the  epidemic  carriers  are  apt  to  increase  their  venornous  attributes." 

In  the  matter  of  remedies,  "  cures,"  and  preventives,  imagination  and 
memory  ran  riot.  There  were  the  "  experienced  mother,"  the  public-spirited 
citizen  offering  to  reveal  a  family  formula  for  $1,000  to  $2,500,  the  generous 
sales  agent  of  patent  medicines  who  would  supply  the  formula  if  accompany- 
ing gallon  sample  gave  good  results,  the  layman  from  rural  counties  whose 
results  in  personal  use  of  croton-oil,  opium,  and  other  powerful  medicaments 
over  the  course  of  many  years  disclosed  a  lifetime  of  illegal  practice  upon  a 
too  gullible  public. 

In  addition  to  these,  there  were  109  suggestions  to  use  internal  remedies 
from  table  salt  (and  no  water)  to  a  serum  made  from  "  blood  of  frogs  "  and 
intraspinal  injections  of  fresh  human  saliva.  Tonics  of  "  boneset  catnip, 
skullcap  and  lady  slipper,"  inhalations  of  smoke  of  burning  leather,  free  use 
of  rum,  champagne  and  brandy,  all  for  little  children,  came  strongly 
endorsed,  though  a  few  were  so  fanatical  as  to  urge  closing  the  saloons. 

Forty  helping  minds  described  baths,  from  the  useful  warm  water  kind 
to  those  in  liquid  sulphide  of  iron,  sand,  mud,  ice,  blueing  water,  etc. 

Thirty-two  more  had  a  certain  remedy  in  disinfectants,  to  be  used  in 
every  room  in  the  city,  or  only  in  the  nose,  or  on  the  hands  of  car  conductors, 
etc. 

Thirty-nine  were  sure  the  use  of  poultices,  blisters,  liniments,  and  heal- 
ing oils  would  save  every  child-victim's  life. 

Here  we  renewed  our  youth  by  finding  Jack  and  Jill  and  their  "  vinegar 
and  brown  paper  "  in  the  pharmacopoea.  The  suggestion  of  "  earthworm 
oil  "  brings  to  mind  the  ingredients  used,  doubtless  with  as  good  effect  by 
the  witches  in  "  Macbeth." 

Of  the  special  diets,  garlic  and  onions  were  the  most  popular.  Of  course 
the  practitioners  of  osteopathy  and  chiropraxy  urged  their  services  upon  a 
suffering  public  with  statements  of  cures. 

Serum,  whether  of  snake  or  human,  horse  or  toad,  was  popular  for  a 
period. 


n 

Charms  to  be  hung  about  the  neck,  red  pepper,  garHc,  asafoetida, 
camphor,  prayer,  "  power,"  spiritual  preventives.  Trances,  electrical  ioniza- 
tion, X-Ray,  the  "  static  modalities  "  all  had  their  devotees,  some  making 
offers  in  all  charity,  others  expecting  a  good  round  sum  for  their  benefi- 
cence. 

The  prize  suggestion  came  from  abroad,  in  the  form  of  the  following 
description :  "  Place  hydrogen  conductors  at  soles  of  feet  and  hands,  and 
cause  attraction  for  this  fine  hydrogen  by  neg.  electricity  or  neg.  applications. 
xA.pply  cantharides  and  mustard  plasters.  Diet  must  be  high  in  fine  oxygen, 
such  as  rice,  bread  and  oxygen  waters.  Give  oxygen  through  lower  ex- 
tremities, by  positive  electricity.  Frequent  baths  using  almond  meal,  or 
oxidizing  the  water.  Applications  of  poultices  of  Roman  chamomile, 
sHppery  elm,  arnica,  mustard,  cantharis,  amygdalae  dulcis  oil,  and  of  special 
merit,  spikenard  oil  and  Xanthoxolinum.  Internally  use,  caffeine,  Fl.  Kola, 
dry  muriate  of  quinine,  elixir  of  cinchona,  radium  water,  chloride  of  gold, 
liquor  calcis  and  wine  of  pepsin."  One's  only  embarrassment  would  be 
which  one  to  use  first. 

Suggestions  were  acknowledged  and  in  all  instances  in  which  there  was 
any  published  clinical  record  of  favorable  results,  the  treatment  suggested 
was  submitted  to  the  Medical  Boards  of  the  Department  of  Health  Hospi- 
tals for  consideration.  As  will  be  seen  from  the  report  of  treatment  at  the 
hospitals,  various  therapeutic  measures  were  carefully  studied. 

Results  and  Plans. 

Most,  if  not  all,  the  questions  which  have  been  asked  upon  two  matters 
of  first  importance  to  the  citizen,  whether  parent  or  merely  taxpayer,  cannot 
be  answered  without  qualifications. 

What  has  been  accomplished  in  the  methods  of  controlling  epi- 
demic poliomyelitis? 

What  is  planned  in  order  to  prevent  or  control  the  next  epidemic, 
when  it  occurs,  next  year,  or  in  the  more  remote  future? 

It  must  be  said  that  there  is  no  positive  proof  that  a  demonstrable 
amount  of  protection  or  prevention  resulted  from  the  general  measures 
enforced.  That  it  is  wise  to  separate  the  sick  from  the  well  as  promptly  as 
possible,  after  the  detection  of  communicable  disease,  in  epidemics,  cannot 
be  denied,  and  this  measure  of  precaution  must  be  accepted  on  general 
principles  while  awaiting  such  facts  as  may  permit  of  the  use  of  specific 
measures  appropriate  for  this  particular  disease.  Two  apparently  just 
inferences  may  be  drawn  from  a  study  of  the  records : 

1.  That  hospitalization,  when  prompt  and  applied  to  all  but  mori- 
bund cases,  probably  checks  the  spread  of  the  disease  and  determines  a 
loAver  incidence  under  similar  housing  conditions  than  where  removal 
to  hospitals  is  delayed  and  many  cases  are  left  in  their  homes. 


78 

In  Brooklyn,  only  46%  of  the  cases  suitable  for  removal  were  taken 
from  homes  to  isolation  hospitals.  In  Manhattan,  96%  of  the  suitable  cases 
were  hospitalized,  and  the  administrative  machinery  was  more  effective  at 
the  time  when  the  majority  of  the  cases  were  reported  in  Manhattan;  hence, 
removals  followed  diagnosis  more  promptly  than  was  the  case  in  Brooklyn, 
where  the  full  force  of  the  epidemic  fell  before  the  emergency  organization 
was  well  established. 

It  cannot  be  claimed  that  all  other  factors  have  been  excluded,  but  it  is 
nevertheless  suggestive  that  in  spite  of  greater  congestion  and  apparently 
more  opportunities  for  contact  infection,  because  of  the  larger  population  per 
acre  in  Manhattan,  the  case  incidence  of  the  disease  was  .94  per  1,000  of 
population  in  that  Borough,  while  it  reached  2.24  in  the  Borough  of  Brook- 
lyn. 

2.  Isolation  of  groups  of  children  from  contact  with  other  children 
or  adults,  even  when  carried  out  in  the  midst  of  areas  where  the  disease 
is  prevalent,  suffices  to  protect  such  children  almost  absolutely  from 
infection,  in  spite  of  the  use  of  identical  water  and  food  supplies),  and 
exposure  to  the  same  atmospheric  conditions  and  winged  insects. 

In  support  of  this,  the  following  facts  are  presented: 

There  were,  during  the  epidemic,  in  New  York  City,  93  institutions  for 
the  permanent  care  of  children,  such  as  asylums  and  charitable  homes  with  a 
total  census  of  21,746,  and  76  institutions  for  the  temporary  care  of  children, 
such  as  recreation  camps  and  convalescent  homes,  with  a  total  census  of 
6,365. 

All  of  these  institutions  were  under  the  strict  control  and  supervision  of 
the  Department  of  Health,  and  were  notified  on  July  5th,  by  mail,  and  at 
different  dates  between  July  5th  and  14th,  by  personal  visits  of  the  inspect- 
ors, to  discontinue  the  admission  of  visitors  until  further  notice  (rescinded 
Nov.  1). 

The  experience  with  the  institutions  for  temporary  care  was  as  follows : 
In  the  Sea  Breeze  Home  at  Coney  Island : 

One  case  developed  on  the  afternoon  of  July  17th,  within  a  few 
hours  of  admission,  though  with  a  normal  temperature  and  apparently 
normal  on  medical  examination  on  the  morning  of  the  same  day. 

One  case  developed  on  August  26th,  five  days  after  admission. 

There  were  2,087  inmates  under  sixteen  years  of  age,  during  the 
summer. 

In  both  these  cases,  there  is  no  reason  to  doubt  the  existence  of  infection 
previous  to  admission. 


79 

At  the  New  York  Foundling  Hospital : 

One  case  was  brought  to  the  hospital  with  a  developed  paralysis 
and  fever  by  the  foundling  keeper  from  her  home.  August  27th. 

One  case  (S.  S.,  age  4  years)  developed  the  disease  on  July 
30th,  seven  days  after  admission. 

One  case  (G.  G.,  age  2  years)  developed  the  disease  on  August 
8th,  nine  days  after  the  previous  case  (S.  S.)  had  been  removed 
from  the  adjacent  bed. 

One  case  (S.  R.)  developed  the  disease  on  August  4th,  and, 
though  an  inmate  of  another  ward,  was  in  the  hospital  during  the 
stay  of  the  child  (S.  S.)  No  direct  exposure  is  known,  nor  could  it 
be  proved  that  a  common  nurse  or  attendant  had  sers^ed  these  two 
children. 

One  case  (J.  F.)  developed  the  disease  on  September  19th.  This 
child  had  been  in  the  hospital  for  some  time  and  the  source  of  in- 
fection was  not  traced. 

There  were  650  inmates  in  the  New  York  Foundling  Hospital 
during  the  summer. 

At  the  Home  for  Destitute  Children : 

The  exclusion  of  visitors  was  not  observed  until  July  14th. 
Three  cases  developed  on  July  18th,  21st  and  24th,  respectively.  It 
was  learned  that  after  July  14th  on  several  occasions  visitors  gained 
access  to  the  children  by  irregular  means,  and  the  children  were  not 
infrequently  taken  out  to  walk  in  Prospect  Park.  It  is  worth  noting 
that  all  three  cases  developed  within  the  time  accepted  as  the  usual 
incubation  period  of  the  disease,  5  to  10  days  after  July  14th,  when 
quarantine  was  undertaken. 

At  the  Angel  Guardian  Home : 

Quarantine  was  not  observed  until  July  14th.  One  case  de- 
veloped on  July  27th.  This  child  had  been  an  inmate  of  the  institu- 
tion for  two  years.  No  other  cases  of  illness  occurred  in  the 
institution  during  the  summer  which  could  be  confused  with  non- 
paralytic cases  of  poliomyelitis.  There  were  a  number  of  cases  in  the 
vicinity  of  this  institution,  but  the  source  of  infection  in  this  case  was 
not  traced.     No  secondary  cases  developed  among  the  600  inmates. 

At  the  Sheltering  Arms  Nursery : 

One  case  developed  on  July  1st.  No  secondary  cases  and  no 
cases  of  any  other  disease  developed  during  the  summer,  among  the 
116  inmates. 

Among  the  institutions  for  the  permanent  care  of  children,  two  cases 
occurred : 

At  St.  Joseph's  Home,  Flushing,  one  child  (C.  M.),  who  had 
been  an  inmate  for  two  years,  developed  poHomyelitis  on  August  8th. 
Quarantine  had  been  observed  since  July  14th.  On  the  same  day  a 
child  of  the  engineer  of  the  institution,  living  in  a  house  adjacent 
to  the  Home,  developed  the  disease.  The  source  of  the  infection 
was  not  traced.  No  secondary  cases  occurred,  although  the  child 
(C.  M.)  had  been  kept  from  August  8th,  when  her  first  symptoms 


80 

of  undefined  sickness  were  developed,  until  August  13th  (when  the 
diagnosis  was  definitely  established,  and  she  was  removed  to  the 
Queensboro  Hospital),  in  the  Baby  House  with  thirty  other  children 
between  two  and  six  years  of  age. 

At  St.  Joseph's-by-the-Sea,  Huguenot  Park,  Borough  of  Rich- 
mond, one  of  the  97  children  developed  a  disease  diagnosed  as  polio- 
myelitis on  August  23rd.  At  no  time  was  the  diagnosis  positively 
established,  and  when  death  occurred  on  September  29th,  after  almost 
continuous  unconsciousness  since  the  onset,  the  autopsy  did  not  give 
definite  proof  of  the  cause  of  death.  No  secondary  cases  occurred. 
Quarantine  had  been  carefully  observed  since  July  4th. 

Allowing  for  the  two  weeks  for  incubation  and  development  of  cases 
after  exclusion  of  visitors,  and  the  observance  of  regulations  at  the  various 
institutions,  and  eliminating  the  cases  which  came  to  institutions  with  the 
disease  developed  and  cases  in  which  the  diagnosis  was  made  almost  immedi- 
ately after  admission,  we  have  an  astonishing  evidence  of  the  value  of  isola- 
tion of  children  of  the  especially  susceptible  ages  out  of  contact  with  the  rest 
of  the  community.  We  have  furthermore  good  reason  to  feel  that  the  pre- 
cautions as  to  personal  hygiene  and  management  of  groups  of  children  in 
institutions  suffice  to  prevent  the  spread  of  disease  within  their  walls. 

Two  further  important  observations  were  made,  leading  to  the  conclu- 
sion that  isolation  of  groups  of  children  prevented  their  infection.  There 
were  between  80  and  90  children  on  Governor's  Island,  the  United  States 
Government  Military  post,  throughout  the  epidemic.  They  were  living 
under  as  nearly  ideal  sanitary  conditions  as  may  well  be  obtained.  Absolute 
exclusion  of  all  children  visitors  to  the  Island  was  maintained  from  July  4th. 
The  children  of  the  Island  were  not  allowed  to  leave  until  the  middle  of 
September.     No  cases  developed. 

There  were  350  children,  under  16  years  of  age,  on  Barren  Island  in 
Jamaica  Bay,  Borough  of  Brooklyn.  To  this  Island  all  the  city  garbage  and 
ofifal  is  taken  for  reduction  in  the  large  rendering  plants.  Flies  and  mos- 
quitoes are  abundant.  Rats  are  numerous.  There  is  no  public  water  supply 
and  there  are  many  shallow  surface  water  wells.  There  is  no  sewage  system. 
There  are  few,  if  any,  cellars.  There  is  no  garbage  collection.  There  are 
no  public  highways.  The  population  of  about  1,300  people  represents  the 
lower  grade  of  unskilled  labor,  Poles,  Italians  and  Negroes  predominating. 
The  standard  of  living  is  low.  No  cases  of  poliomyelitis  developed  on 
Barren  Island.  It  is  probably  correct  to  say  that  social  and  geographical 
isolation  of  this  Barren  Island  group  accomplished  by  accident  what  was 
enforced  by  regulations  at  Governor's  Island,  namely,  group  isolation  which 
was  effective  regardless  of  environment. 

A  result  of  great  importance  may  properly  be  attributed  to  the  educa- 
tional campaign  carried  on  among  the  mothers  of  little  children.  In  spite  of 
the  large  number  of  deaths  from  poliomyelitis,  among  babies  and  children 
under  five,  the  ratio  of  deaths  from  all  other  causes  among  children  in  this 
age  group  were  less  than  ever  before  in  the  history  of  the  City. 


81 

With  regard  to  possible  or  probable  recurrence  of  the  disease  in 
epidemic  form  in  the  immediate  future  and  the  plans  prepared  for  its  control, 
no  better  statement  can  be  had  on  the  first  point  than  is  to  be  found  in  the 
report  of  the  State  Medical  Institute  of  Sweden  of  1912.  "  Those  places 
which  have  once  been  severely  affected  by  the  disease  have  all  prospects  of 
escaping  renewed  severe  outbreak  of  the  epidemic  even  should  this  not  occur 
until  after  the  lapse  of  a  series  of  years."  "  In  all  probability  in  the  part  of 
the  population  chiefly  affected,  there  is  a  general  and  widespread  immunity 
against  a  renewed  infection." 

In  preparing  to  meet  and  control  the  disease  if  or  when  it  reappears,  we 
must,  until  new  information  as  to  carriers  and  means  of  transmission  is 
forthcoming,  rely  upon  early  diagnosis,  prompt  notification,  hospitalisation 
or  equivalent  home  isolation,  a  well-informed  public  and  an  alert  medical 
profession. 

During  the  recent  epidemic,  the  medical  profession,  always  the  first  line 
of  defense  against  communicable  disease,  gave  freely  of  its  devoted  service ; 
the  pubHc  acted  in  the  main  wisely  in  response  to  the  appeal  for  quicker  and 
better  care  for  sick  children ;  the  quality  of  diagnosis  rapidly  improved  with 
more  general  familiarity  of  physicians  with  the  disease ;  prompt  notification 
was  the  rule ;  hospitalization  benefited  the  patients  and  safeguarded  the 
public.  These  things  have  been  accomplished,  and  our  reliance  upon  them 
is  wholly  justified. 


CHAPTER  II. 

Etiology. 

Historical — 

Until  recently  nothing  was  definitely  known  of  the  etiology  of  poliomye- 
litis. Within  the  last  few  years,  however,  a  series  of  studies  have  been  made 
which  have  added  considerably  to  our  knowledge  of  its  cause  and  trans- 
mission. 

In  the  spring  of  1909,  Landsteiner  and  Popper^  succeeded  in  trans- 
mitting the  disease  to  monkeys  by  inoculating  them,  intraperitoneally, 
with  the  spinal  cord  of  a  child  who  died  of  poliomyelitis,  but  they  did  not 
succeed  in  transmitting  the  infection  from  monkey  to  monkey,  probably 
because  they  used  too  mild  a  case.  Later,  in  1909,  Flexner  and  Lewis- 
obtained  the  same  result  and  further  transmitted  the  infection  from  mon- 
key to  monkey  through  an  indefinite  number  of  passages.  Landsteiner 
and  Levaditi^,  in  1909,  also  transmitted  the  disease  from  monkey  to  mon- 
key and  found  that  the  virus  remained  virulent  for  some  time  outside  of 
the  body ;  that  the  degenerated  nerve  cells  are  taken  up  by  phagocytes ;  and 
that  there  is  an  analogy  between  the  lesions  of  poliomyelitis  and  those  pro- 
duced by  rabies.  They  also  demonstrated  that  the  virus  is  filtrable.  Leiner 
and  Weisner^  transmitted  the  infection  from  monkey  to  monkey,  and 
found  that  young  animals  were  more  susceptible  to  infection  than  older 
ones,  and  that  the  spinal  fluid,  blood  and  spleen  were  negative.  Flexner  and 
Lewis^  transmitted  the  disease  by  inoculating  very  large  amounts  into 
the  blood  or  peritoneal  cavity,  also  by  the  subcutaneous  method,  and 
independently  found  the  virus  to  be  filtrable.  Landsteiner  and  Levaditi*^ 
found  the  virus  in  the  salivary  glands,  and  suggested  the  saliva,  moist 
or  dry,  as  a  source  of  infection.  They  also  found  the  spinal  fluid  negative 
in  monkeys  dying  from  artificial  infection. 

Soon  after  this,  in  1913,  Noguchi  and  Flexner^  announced  that  they  had 
obtained  cultures  in  media  similar  to  the  medium  used  by  Noguchi  in  culti- 
vating spirochetes.  In  such  media,  in  about  five  days,  the  pieces  of  tissue 
employed  become  surrounded  by  an  opalescent  haze  which  increases  for  five 
days  more,  and  a  sediment  gradually  forms.'  Giemsa's  stain  shows  the 
presence  of  minute  globoid  bodies  (0.15  to  0.13  microm,  diam.)  in  pairs, 
short  chains  and  masses.  Cultures  were  also  obtained  from  the  filtered  virus. 
Monkeys  inoculated  with  these  cultures  for  a  variable  number  of  culture 
generations  may  die  with  typical  lesions  of  the  disease.  The  authors  con- 
sider these  bodies  the  cause  of  the  disease.     They  further  report  that  the 

1 — Landsteiner  and  Popper — Ztschr.  f.  Immunitatsforsch,  1909,  11,  377. 

2— Flexner  and  Lewis,  Jour.  Amer.  Med.  Assoc,  1909,  LIII,  1639,  1913  and  2095. 

3 — Landsteiner  and  Levaditi,  Compt.  Rend.  Soc.  Biol..  1909,  LXII,  592. 

4— Leiner  and  Weisner,  Wiener  Klin.  Woch.,  1909,  XXII,  1698. 

S— Landsteiner  and  Levaditi,  Compt.  Rend.  Soc.  de  Biol.,  1909,  LXVII,  787. 

6 — Flexner  and  Noguchi,  Jour.  Exp.  Med.,  1913,  XVIII,  461. 


83 

cultures  are  filtrable  through  the  coarser  filters.  Levaditi  states  that  he 
cannot  obtain  the  results  of  Noguchi,  but  that  he  obtains  evidence  of  growth 
by  the  living  tissue  method.  Flexner  and  his  co-workers'^  have  not  shown 
that  their  cultures  produced  immunity.  Their  chain  of  evidence,  therefore, 
as  to  the  specificity  of  their  cultures  in  etiology  is  incomplete. 

Rosenow  and  his  co-workers*  claim  that  they  have  obtained  a  par- 
ticularly irregular  streptococcus  from  the  central  nervous  system  and  the 
tonsils  of  all  the  human  and  monkey  cases  examined  by  them ;  that  they  have 
found  it  slightly  filtrable ;  and  that  it  produced  typical  lesions  not  only  in 
monkeys,  but  in  many  other  animals.  But  they  have  not  yet  shown  that  it 
produced  immunity.  Rosenow  states  further  that  his  streptococcus  is  the 
.same  organism  as  the  minute  coccoid  organism  obtained  by  Noguchi,  and  he 
attempts  to  prove  this  by  morphologic  demonstration  of  the  breaking  off  of 
minute  forms  from  larger  forms.  He  has  not  shown,  however,  that  such 
minute  forms  remain  minute,  and  that  they  grow  only  anaerobically. 
Neither  has  he  satisfactorily  explained  why  he  obtains  so  many  more  lesions 
in  different  animals  wnth  his  cultures  than  with  his  virus.  Furthermore, 
others  have  already  claimed  that  the  paralyses  produced  by  streptococci  in 
those  animals  susceptible  to  the  virus  (monkeys,  and  to  less  extent  rabbits) 
are  not  accompanied  by  lesions  similar  to  those  produced  by  the  virus. 

What  Is  Kiwzi'ii  as  to  the  Cause  and  Transniission  of  Poliomyelit'is — 

Summarizing  the  results  obtained  from  laboratory  investigations,  the 
following  facts  regarding  the  cause  and  transmission  of  the  disease  may  be 
said  to  have  been  practically  established : 

(1)  The  specific  cause  of  poliomyelitis  is  a  so-called  filtrable  virus; 
i.  e.,  a  virus  that  will  pass  through  the  Berkefeld  filter,  and  is  invisible  under 
the  microscope  in  some  of  its  forms;  "ultra-microscopic"  as  that  term  is 
generally  understood.  AVhile  various  micro-organisms  have  been  described 
and  claimed  to  be  the  cause  of  the  disease,  absolute  proof  of  any  one  of  these 
being  the  specific  etiological  agent  is  lacking.  However,  the  organism  found 
in  cultures  of  the  virus  as  described  by  Flexner  and  Noguchi  is  clearly  seen 
under  microscope. 

(2)  The  virus  obtained  from  human  cases  of  this  disease  injected  into 
monkeys  produces  in  them  characteristic  effects  almost  identical  with  those 
produced  in  man.  The  only  animals,  other  than  monkeys,  that  are  definitely 
susceptible  to  the  infection  are  rabbits,  but  the  susceptibility  of  these 
animals  is  highly  inconstant,  and  the  effects  produced  are  unlike  those  pro- 
duced in  monkeys. 

(3)  The  virus  has  been  demonstrated  in  the  tissues  and  secretions  of 
persons  dead  of  poliomyelitis,  namely,  in  the  brain  and  spinal  cord,  the 
mesenteric  glands,  in  the  tonsils,  and  in  the  mucous  secretions  of  the  naso- 
phar}'nx,  the  trachea  and  the  intestines ;  also  in  the  secretions  of  persons 

7 — Flexner  and  Co-workers,  Jour.  Exp.  Med..  1913  and  1914. 

8— Rosenow,  Towne  and  Wheeler,  Jour.  Amer.  Med.  Assoc,  1916,  LXVH,  1202. 


84 

acutely  ill  with  poliomyelitis,  namely,  in  the  naso-pharyngeal  secretions,  and 
in  washings  from  the  rectum;  also  in  the  naso-pharyngeal  and  intestinal 
secretions  of  persons  convalescing  from  acute  attacks  of  poliomyelitis,  and 
in  the  naso-pharyngeal  secretions  of  apparently  well  persons  who  have  been 
more  or  less  intimately  associated  with  other  persons  suffering  from  polio- 
myelitis. 

(4)  Outside  of  the  human  body,  the  virus  is  reported  as  having  been 
found  in  nature  in  the  dust  of  rooms  occupied  by  poliomyelitis  patients. 
The  virus  has  been  shown  to  be  very  resistant  to  the  influence  of  low 
temperatures,  certain  standard  disinfectants  (such  as  carbolic  acid)  and 
drying  by  sunlight,  although  it  is  readily  killed  by  high  temperatures. 

(5)  As  to  the  modes  by  which  the  virus  may  enter  the  human  body 
to  cause  infection,  the_se  can  be  only  inferred  from  experiments  which  have 
been  made  on  animals.  Monkeys  have  been  experimentally  infected  by 
injection  of  virus  directly  into  the  brain,  into  the  general  circulation,  into  the 
peritoneal  cavity,  and  even  into  the  skin.  They  have  been  infected  by  rub- 
bing the  virus  upon  the  scarified  mucous  membrane  of  the  nose,  and  also  by 
rubbing  it  upon  the  uninjured  mucous  membrane.  It  has  also  been  found 
possible  to  produce  infection  by  feeding  monkeys  through  a  stomach  tube 
with  massive  doses  of  the  virus. 

Although  the  results  obtained  from  laboratory  experiments  concerning 
natural  modes  of  infections  are  somewhat  inconclusive,  they  would  seem  tio 
indicate  that  the  most  probable  means  of  transmission  of  the  disease  in 
nature  are  such  as  usually  serve  to  transmit  secretions  from  infected  persons 
to  the  respiratory  (or  digestive)  tract  of  others,  namely,  by  more  or  less 
direct — i.  e.,  direct  or  indirect,  immediate  or  intermediate — personal  contact. 

The  resistance  of  the  virus  to  the  action  of  drying  and  sunlight,  together 
with  the  fact  that  dust  from  a  sick  room  has  been  found  experimentally 
infective,  would  suggest  the  possibility  of  the  infection  being  spread  by  dust 
and  fomites,  but  this  has  not  been  positively  demonstrated. 

It  has  also  been  experimentally  shown  that  the  infection  may  be  trans- 
mitted from  monkey  to  monkey  through  the  agency  of  a  biting  fly  (the  stable 
fly) ,  and  in  one  instance  by  the  bedbug.  These  observations  would  indicate 
that  poliomyelitis  may  possibly  be  an  insect-borne  disease.  But  isolated  cases 
such  as  these  in  animals  do  not  prove  that  insects  play  an  important  part  in 
the  transmission  of  the  disease  to  man. 

But  by  whatever  means  the  virus  may  be  transmitted,  having  once 
gained  entrance  into  the  body,  it  circulates  with  the  blood  stream  and  thus 
produces  the  disease. 

One  attack  of  poliomyelitis  apparently  confers  a  high  degree  of  im- 
munity.   Recurrent  cases  and  second  attacks  have  been  reported. 

Original  Investigations  of  the  Research  Laboratory — 

During  and  since  the  recent  epidemic  of  poliomyelitis  in  1916,  original 
investigations  as  to  the  cause  and  transmission  of  the  disease  have  been 


85 

undertaken  by  the  Research  Laboratories    of    the    Department  of  Health. 
Fresh  material  has  been  available  for  the  following  studies : 

1st :  The  inf activity  of  the  spinal  fluid  from  human  poliomyelitis. 

2d :  Characteristics  of  the  virus  of  the  1916  epidemic  in  monkeys. 

3d :  Problems  of  immunity,  active  and  passive. 

4th  :  Problems  of  transmission. 

5th :  Cultural  studies  on  etiology. 

Some  of  this  work  has  been  completed,  but  much  of  it  is  still  in  progress 
of  investigation.  The  following  is  the  result  of  the  work  so  far  accom- 
plished : 

Infectivity  of  the  Spinal  Fluid  From  Human  Poliomyelitis — 

Repeated  attempts  have  been  made  to  demonstrate  the  virus  of  polio- 
myelitis in  the  spinal  fluid  of  infected  human  beings,  but  so  far  all  have 
proved  negative.  Flexner  and  Lewis*  have  shown  its  presence  in  the  spinal 
fluid  from  an  infected  monkey  drawn  three  days  after  the  time  of  intra- 
cerebral injection  of  virus.  This  fact  would  indicate  that  it  is  present  in  the 
fluid  at  some  stage  during  the  period  of  incubation.  Whether  the  virus 
diminishes  rapidly,  though  not  wholly  disappearing  with  the  onset  of  symp- 
toms, or  whether  it  is  present  in  the  later  stages  in  such  minute  quantities 
that  it  cannot  be  demonstrated  by  animal  inoculation,  it  is  impossible  to  say. 
In  this  experiment,  undertaken  to  determine  whether  or  not  the  aggre- 
gate of  a  number  of  spinal  fluids  from  positive  cases  of  poliomyelitis  contains 
sufficient  virus  to  infect  a  monkey,  the  fluids  from  fort}'  cases  were  centri- 
fuged  at  high  speed  for  three-quarters  of  an  hour.  The  sediment,  amounting 
to  1  c.  c.  of  ver}'  turbid  fluid,  was  injected  intracerebrally  into  Rhesus  No. 
23.  No  effects  were  noted,  and  after  an  observation  period  of  two  months 
this  animal  was  inoculated  with  ]/>  c.  c.  of  a  10  per  cent,  suspension  of  No. 
VII  General  Virus.  After  an  incubation  period  of  eleven  days,  paralysis 
appeared  in  the  left  leg :  the  paralysis  then  involved  the  right  leg,  but  failed 
to  progress  further.    The  animal  is  alive  and  improving. 

It  would  appear  from  the  foregoing  experiment,  therefore,  that  there  is 
little,  if  any,  infective  virus  present  in  fluids  of  human  poliomyelitis. 

Poliomyelitis  in  Monkeys  From  Virus  of  the  1916  Epidemic — 

The  first  attempts  to  produce  the  disease  in  monkeys  resulted  in  failures. 
On  account  of  the  lack  of  the  supply  of  fresh  monkeys,  two  animals,  both  of 
the  Rhesus  variety,  that  had  been  the  property  of  the  Department  for  several 
years,  were  used.  These  received  heavy  suspensions  of  material  from  the 
brains  and  cords  of  two  cases  that  were  clinically  and  pathologically  un- 
doubted cases  of  acute  poliomvelitis.  The  animals  received  J/2  c.  c.  of  a  20 
per  cent,  saline  emulsion  intracerebrally,  and  2  c.  c.  of  the  same  suspension, 
into  the  tissues  around  each  sciatic  ner\'e.     After  one  month's  observation, 

*J.  A.  M.  A.,  April  2,  1910—154,  p.  1140. 


86 

these  inoculations  were  repeated  with  glycerinated  material  of  the  same 
cases,  but  in  addition  they  received  10  c.  c.  of  the  virus  suspension  intra- 
peritoneally.  The  second  inoculations  were  no  more  successful  than  the  first. 
These  monkeys  (Nos.  98  and  102)  later  received  massive  inoculations  by 
three  routes,  intracerebral,  perisciatic  and  intraperitoneal,  of  known  virulent 
material  from  a  monkey  of  the  second  generation.  These,  too,  proved  un- 
successful. 

It  was  decided  that  these  monkeys  being  refractory  to  infection  would 
serve  better  as  a  source  of  immune  serum  for  later  experiments. 

Brain  and  cord  material  from  three  new  cases,  that  were  clinically  posi- 
tive cases  of  acute  poliomyelitis,  was  then  inoculated  by  three  routes,  intra- 
cerebrally,  perisciatic,  intraperitoneally,  into  two  monkeys  from  a  fresh 
supply,  one  being  a  Rhesus  and  the  other  a  Sapajou,  a  South  American  ring 
tail  monkey.  They  received  Yz  c.  c,  2  c.  c.  and  10  c.  c.  of  a  20  per  cent  sus- 
pension of  this  material,  respectively,  in  the  three  ways  above  mentioned. 

On  the  seventh  day  after  inoculation  monkey  No.  1,  the  Rhesus,  pre- 
sented tremors  of  the  head  and  weakness  in  the  left  leg.  This  condition 
progressed  to  complete  paralysis  of  the  limbs,  first  left  leg,  then  right  leg, 
left  arm,  right  arm,  convulsions  and  respiratory  failure.  He  died  on  the 
third  day  after  the  appearance  of  muscular  weakness. 

Monkey  No.  2,  a  Sapajou,  has  exhibited  no  symptoms  at  this  writing, 
three  and  a  half  months  after  injection. 

Two  other  animals  of  this  variety  were  subsequently  inoculated  with  a 
virulent  virus,  but  these,  too,  were  unsuccessful,  confirming  the  unsuitability 
of  this  type  of  monkey  for  experimental  work  in  the  study  of  poliomyelitis. 

No  further  difficulty  was  experienced  in  passing  of  virus  obtained  from 
monkey  No.  1  through  a  series  of  16  monkeys,  14  of  the  Rhesus  variety,  and 
two  South  American  Mangabeys.  The  virus  is  now  in  the  eighth  generation 
and  exhibits  evidence  of  increasing  virulence. 

The  animals  of  the  second  and  third  generations  were  inoculated  with 
heavy  suspensions  of  the  brain  and  cord  material  by  the  three  -ways  men- 
tioned, but  subsequent  animals  were  infected  by  injection  of  ^  c.  c.  of  10 
per  cent,  suspension  into  the  brain.  The  last  two  animals  received  ^  c.  c.  of 
5  per  cent,  suspension  intracerebrally. 

The  technique  followed  was  that  in  use  at  the  laboratory  for  the  prepa- 
ration of  anti-rabic  treatment.  Fresh  brain  and  cord  material  was  weighed 
and  ground  up  in  a  sterile  mortar  and  sterile  salt  solution  added  to  make  the 
desired  strength.  The  intracerebral  inoculations  were  always  in  the  right 
cerebral  hemisphere.  The  animals  were  anesthetized,  and  incision  was  made 
in  the  middle  of  the  scalp  over  the  forward  part  of  the  skull.  The  wound 
was  retracted  to  the  right  side  and  a  small  trephine  opening  made  with  an 
awl  in  the  right  frontal  bone  one-fourth  inch  anterior  to  the  coronal  suture, 
and  just  to  the  right  of  the  sagittal  suture.  The  suspension  was  injected 
very  slowly.  It  is  well  not  to  incise  the  pericranium,  for,  if  intact,  it  acts  as 
a  valve  over  the  site  of  the  trephine  opening  and  prevents  the  escape  of  the 


87 

injected  material.  The  retracted  scalp,  when  it  resumes  its  normal  position, 
also  aids  in  the  prevention  of  leakage.  In  performing  the  peri-sciatic 
inoculations,  care  was  taken  to  place  the  needle  in  close  relation  to  the 
posterior  aspect  of  the  middle  of  the  femur  before  expelling  the  material. 

Of  the  seventeen  animals  inoculated,  all  but  two  (Rhesus  No.  50 
and  No.  51)  exhibited  frank  signs  of  paralysis.  On  the  fourth  day  after 
inoculation.  No.  50  became  quite  subdued  and  huddled  in  a  corner  of  the 
cage.  On  being  forced  to  move,  it  was  noticed  that  he  limped  slightly  on 
the  right  hind  leg.  This  animal  then  received  two  intra-spinal  injections  of 
serum  obtained  from  Rhesus  No.  102  on  successive  days.  The  animal 
seemed  to  improve  rapidly,  and  at  this  date  shows  no  weakness  in  any 
muscle.  This  was  the  only  animal  that  appeared  to  limp.  Five  others,  simi- 
larly treated,  did  not  show  symptoms. 

Rhesus  No.  51  exhibited  symptoms  of  distress  on  the  fourth  day 
after  inoculation,  which  consisted  of  tremors  and  general  weakness;  he 
showed  no  evidence  of  paralysis  in  any  limb.  This  general  muscular  weak- 
ness progressed,  and  the  monkey  died  on  the  third  day  after  onset  of  symp- 
toms. The  brains  showed  hyperaemia,  and  sections  of  the  cord  presented 
redness  and  swelling  of  the  gray  matter.  The  lungs  and  other  organs  were 
apparently  normal.  This  form  of  the  disease  in  monkeys  has  been  encoun- 
tered many  times  by  workers  in  this  field,  and  has  been  called  the  marantic 
type  of  monkey  poliomyelitis.  Subsequent  inoculations  with  material  from 
this  animal  produced  the  typical  spinal  type  of  paralysis. 

The  incubation  period  of  this  series  was  from  four  to  thirteen  days. 
Eight  (or  47%)  developed  paralysis  on  the  seventh  day,  two  on  the  eighth 
day,  two  on  the  fourth  day,  and  one  each  on  the  fifth,  tenth,  eleventh, 
twelfth  and  thirteenth  days  after  inoculation. 

Twelve  of  the  seventeen  animals  died  (a  mortality  of  71%).  Of  the 
remaining  five,  four  exhibited  residual  paralysis.  The  average  duration  of 
illness,  for  eleven  of  the  twelve  fatal  cases,  was  four  days,  the  limits  be- 
ing two  and  seven  days.  Rhesus  No.  25  died  twenty  days  after  onset  of 
paralysis.  This  animal  previously  had  been  inoculated  with  brain  and  cord 
material  from  a  rabbit,  and  exhibited  flaccid  paralysis  of  a  progressive  type. 
The  present  inoculation  produced  no  effects,  and,  after  an  observation  period 
of  six  weeks,  he  was  again  inoculated  along  with  two  other  animals.  No.  36 
and  No.  37,  with  material  from  No.  26,  fourth  generation.  The  incubation 
period  of  No.  36  and  No.  Z7  was  seven  days,  that  of  No.  25  was  thirteen 
days.  With  the  onset  of  the  symptoms,  paralysis  progressed  rapidly  for 
three  days.  Then  the  process  appeared  to  subside  and  the  animal  improved 
for  a  period  of  nearly  two  weeks.  After  this  quiescent  period,  the  paralysis 
began  where  it  left  off,  and  the  animal  died  of  respiratory  failure  on  the 
twentieth  day  of  the  disease. 

The  character  of  the  paralysis  in  all  but  two  of  the  animals  was  that  of 
the  progressive  spinal  type,  beginning  in  the  left  leg,  progressing  to  the  right 
leg,  left  arm,  right  arm,  and  in  the  fatal  cases  to  respiratory  paralysis.    In 


one  animal,  paralysis  appeared  first  of  the  right  leg,  then  left  leg,  left  arm, 
.  right  arm,  and  paralysis  of  respiration.  In  the  other,  the  symptom  appeared 
.  first,  in  the  left  arm,  right  arm,  then  simultaneously  in  both  legs,  and  respira- 
tory paralysis.  In  the  non-fatal  cases,  except  No.  50,  paralysis  extended  to 
the  left  arm,  leaving  the  right  arm  untouched.  With  the  cessation  of  the 
progress  of  the  disease,  the  left  arm  recovered  its  power  to  some  extent,  but 
the  paralysis  of  the  legs  was  permanent. 

The  gross  pathologic  changes  presented  a  similar  appearance  in  all  the 
fatal  cases,  consisting  in  moderate  congestion  of  the  pial  vessels  of  the  brain 
and  cord. 

Cut  sections  of  the  cord  at  various  levels  presented  a  reddening  and 
swelling  of  the  gray  matter,  rendering  it  very  distinct  and  prominent. 

The  microscopic  picture  presented  congestion  and  edema,  some  capillary 
hemorrhage,  peri-vascular  and  also  diffuse  round  cell  infiltration,  and 
ganglion  cells  in  various  stages  of  destruction  and  neurophagia^-all  the 
changes  present  in  human  cases,  except  that  they  are  more  severe  in  the 
experimental  animals. 

Passage  of  this  virus  will  be  continued  with  the  hope  of  increasing  its 
virulence,  so  as  to  permit  us  to  use  filtrates  in  further  work. 

Appended  is  a  chronological  table  of  protocols  of  the  animal  work  here 
recorded. 


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90 

Cultural  Studies  on  Etiology — 

Notwithstanding  their  many  experiments,  full  proof  is  wanting  that 
the  minute  organism  described  by  Flexner  and  Noguchi  in  1911*  is  the 
specific  cause  of  poliomyelitis.  In  the  first  place,  they  have  found  their 
organism  in  only  a  small  percentage  of  the  cases  examined  by  them,  and 
then  in  only  a  few  of  the  many  culture  tubes  examined;  secondly,  their 
cultures  are  filterable  with  difficulty,  while  the  virus  passes  finer  filters  with 
comparative  ease;  thirdly,  their  cultures  have  not  been  found  to  produce 
antibodies  and  give  no  protection  in  the  monkey,  while  the  virus  protects 
in  the  animal ;  fourthly,  the  human  virus,  through  monkey  passage,  increases 
in  virulence,  which  has  not  been  shown  to  be  the  case  with  the  culture 
virus. 

Considering  these  and  other  unsettled  points  regarding  the  etiology 
of  this  disease,  it  seemed  advisable  to  plan  as  full  a  study  as  possible  of 
the  cause. 

Method  of  Handling  Material. 
Autopsy  Material — 

The  autopsies  were  made  under  as  aseptic  precautions  as  possible. 
Such  aseptic  conditions  were  especially  satisfactory  as  carried  out  in 
monkeys.  The  brain,  and  then  the  spinal  cord  were  removed  and  placed 
in  sterile  receptacles.  In  some  cases,  following  Rosenow's  methodf,  before 
removal  of  the  central  nervous  system,  a  portion  of  the  surface  was  seared 
and  a  sterile  capillary  pipette  was  inserted,  and  some  of  the  contents,  both 
the  fluid  from  the  ventricles  and  the  nerve  tissues  from  different  parts 
cf  the  interior  of  the  brain  and  spinal  cord,  were  removed. 

The  material  was  brought  immediately  to  the  laboratory,  and  the  fol- 
lowing culture  media  were  inoculated  from  different  parts,  in  most  cases 
in  the  order  given : 

Veal  agar  plates  with  and  without  0.2^  glucose;  extract  broth  plus 
0.2%  glucose;  veal  broth;  slant  egg  medium  with  and  without  ascitic 
fluid ;  slant  Bordet  medium  with  and  without  ascitic  fluid ;  veal  horse  serum 
agar  tubes  with  and  without  0.2%  glucose;  ascitic  kidney  (prepared  as 
recommended  by  Noguchi). 

Most  of  the  tubes  were  made  with  and  without  albolene,  and  some 
were  placed  in  an  atmosphere  of  nitrogen  as  well.  From  twenty  to  two 
hundred  initial  cultures  were  made  from  each  case.  The  cultures  were 
put  in  the  incubator  at  about  34°  C.  After  these  were  made,  material 
was  then  taken  for  filtering,  some  for  inoculation  of  monkeys  and  rabbits; 
other  material  was  dropped  into  fixatives  for  sections ;  and  still  other  vv^as 
put  into  50%  gylcerine  and  stored  in  the  ice  box  at  about  7°  Co.  for  later 
examinations.  The  remaining  material  from  many  of  the  good  autopsies, 
not  used  by  other  workers,  were  sent  sealed  to  a  cold  storage  plant. 

*  Flexner  and  Noguchi,  Jour.  Exp.  Med.,  1911  and  1913,  VXIII,  461. 
fRosenow,  Journal  Amer.  Med.  Assoc..  1916,  LXVII,  1202. 


91 


Results  from  Cultures — 

The  immediate  results  of  our  primary  cultures  are  given  in  the  follow- 
ing table  : 

Results  from   Primary   Cultures  of  Fresh  Material. 


bMEARS. 


Pure  Clxtures. 


Minute  IMinute 

Strepto-  Strepto- 

bacterium  Strepto-           Other       bacterium 

Similar  to  coccus.           Minute      Similar  to 

FleXner-  Organisms.    Flexner- 

Xoguchi.  Xoguchi. 


btrepto- 
coccus. 


Other 

r^Iinute 

Organisms. 


Human  Cases — 


10. 

4. 

4. 

3. 
'2. 

3. 

5. 


0 

0 

1 

+ 


Monkeys — 

2 + 

2 + 

2 — 

■4 — 


+ 


+ 
+ 


AxiMAL  Controls. 


Human- 


1, 


Monkeys— 

1 

Dogs — 

1 

Cats — 

1 

2 

Rabbits^ 

3 

1 


+ 
+ 


The  above  table  gives  simply  the  results  from  our  fresh  unfiltered 
material. 

We  had  forty  human  autopsies,  one  of  which  proved  not  to  be  polio- 
myelitis, so  that  was  put  with  the  controls.  Out  of  the  thirty-nine  remain- 
ing, twenty-six  showed  in  smears  a  minute  strepto-bacterium  similar  to 
that  obtained  by  Flexner  and  Noguchi"^,  twenty-three  show'ed  streptococci, 
and  eighteen  showed  other  minute  organisms  which  are  still  being  studied. 

It  was  comparatively  easy  to  obtain  pure  cultures  of  streptococcus  from 
most  of  those  tube*^  showing  them  in  smears,  and  pure  cultures  of  the 
several  minute  organisms  not  like  the  Flexner-Noguchi  organism,  but 
owing,  apparently  to  many  contaminations,  only  twice  so  far  have  we 
obtained  pure  cultures  of  a  micro-organism  answering  to  the  organism  as 
described  bv  them. 


Flexner  and  Xoguchi,  Jour.  Exp.  Med..  1913,  XVIII,  461. 


92 

We  fortunately  are  able  to  compare  these  organisms,  since  we  were 
presented  witn  four  strains  of  the  Flexner-Noguchi  germ,  and  they  are  now 
being  closely  studied.     So  far  they  seem  similar. 

Cultu};e  Controls — 

The  largest  number  of  our  cultures  were  made  in  media  to  which 
normal  tissues  were  added,  therefore  all  media  had  to  be  most  carefully 
controlled.  We  found  streptococci  in  our  control  tubes  several  times  and 
found  even  more  frequently  a  small  irregular  bacillus,  with  many  minute 
forms,  growing  rather  slowly,  so  that  the  early  examinations  did  not  show 
it.  Occasionally,  whole  sets  of  our  animal  tissue  cultures  were  contaminated 
by  such  small  organisms. 

Animal  Experiments — 

One  of  our  strains  (P.  7)  was  inoculated  into  a  monkey  on  the  third 
culture  generation  and  produced  in  twenty-four  hours  a  spastic  paralysis 
in  the  arm  opposite  the  lesion.  In  forty-eight  hours,,  the  leg  on  the  same 
side  as  the  arm  became  stiff.  Later,  after  two  or  three  days,  the  arm  became 
better,  but  the  leg  became  weak.  The  leg  continued  in  this  condition  for 
several  weeks,  and  is  still  being  slightly  dragged.  We  expect  to  inoculate 
this  animal  later  with  "  fixed  monkey  virus  "  to  test  his  immunity.  Of 
course,  the  third  culture  generations  do  not  rule  out  passage  of  an  ultra- 
microscopic  filtrable  virus. 

In  our  cultural  work  so  far,  we  have  been  much  hampered  by  the  lack 
of  monkeys.  For  this  reason  we  could  not  test  our  later  culture  generations. 
It  has  been  the  same  with  our  streptococci. 

None  of  the  three  monkeys  inoculated  with  streptococci  from  these 
cases,  obtained  after  the  method  of  Rosenow,  showed  paralysis.  Two 
rabbits  out  of  twelve,  inoculated  with  streptococcus,  showed  paralysis  with 
localization  of  streptococci  in  the  central  nervous  system. 

Relation  Bettveen  the  FJexner-N oguchi  Organism  and  Aerobic  Streptococci. 

Rosenow*  claims  that  his  streptococci,  developed  under  anaerobic  condi- 
tions grow  in  minute  forms  similar  to  the  Flexner-Noguchi  organism,  but 
he  fails  to  show  that  his  streptococci  can  be  made  to  grow  only  anaerobically, 
as  is  the  case  with  the  Flexner-Noguchi  strains. 

From  our  own  studies  of  these  streptococci  and  the  Flexner-Noguchi 
organism  obtained  by  us  compared  with  the  strains  obtained  from  the 
Rockefeller  Institute,  we  must  conclude  that  the  Flexner-Noguchi  organism 
is  quite  distinct  from  any  aerobic  streptococcus  obtained  by  us  from  these 
cases.  Whether  or  not  it  is  the  cause  of  poliomyelitis  we  cannot  yet  say. 
Many  more  inoculations  must  be  done  before  this  can  be  determined. 

We  have  not  obtained  the  Flexner-Noguchi  organism  so  far  from  any 
of  the  filtrates  tested. 


♦Rosenow,  Towne.  and  Wheeler,  Jour.  Amer.  Med.  Assoc.,  1916,  LXVII.  1202. 


CHAPTER  III. 
Epidemiology. 

Owing  to  the  wide  variations  observed  in  different  epidemics  of  polio- 
myelitis, and  on  account  of  the  incompleteness  of  the  available  data  regarding 
its  occurrence  and  distribution,  it  is  difficult  to  give  in  general  terms  definite 
characteristics  of  the  disease.  Nevertheless,  though  much  remains  yet  to  be 
learned,  many  valuable  observations  have  been  recorded  from  experience 
with  past  outbreaks,  which  fairly  represent  most  of  the  prominent  epi- 
demic features  of  poliomyelitis. 

It  may  be  interesting  and  instructive,  therefore,  to  give  a  brief  intro- 
ductory historical  review  of  past  recorded  outbreaks,  in  relation  to  their 
observed  epidemiological  characteristics,  before  taking  up  the  study  of  the 
epidemiology  of  the  1916  epidemic  in  New  York  City. 

Review  of  Past  Epidemics  of  Poliomyelitis. 

Although  poliomyelitis  has  in  the  last  few  years  assumed  a  special  im- 
portance because  of  its  increasing  prevalence,  particularly  in  the  United 
States,  it  is  not  a  new  disease.  It  has  been  known  and  described  by  medical 
writers  and  has  been  appearing  in  epidemic  form,  as  well  as  isolated  cases, 
in  various  parts  of  the  world,  for  many  years. 

The  earliest  notice  of  the  disease  is  to  be  found  in  Scandinavian  litera- 
ture, as  given  by  Underwood  in  1784.  It  was  next  noted  by  Badham  in 
1836,  and  it  is  accurately  described  by  Heine  in  1840.  This  latter  writer, 
through  his  clear  presentation  of  its  clinical  manifestations  at  the  bedside 
and  the  deformities  that  followed,  may  be  said  to  have  first  recognized 
the  disease  as  an  acute  spinal  paralysis  in  children.  Medin  published  his 
celebrated  observations  on  the  Stockholm  epidemic  in  1887.  The  clinical 
significance  of  Medin's  work  remained  almost  unappreciated  until  the  ac- 
cumulated evidence  from  more  recent  epidemics  emphasized  its  value.  As 
with  many  other  diseases,  the  earlier  records  of  poliomyelitis  are  much 
obscured  by  confusion  with  other  maladies,  and  more  especially  has  it  been 
confused  with  meningitis. 

Prior  to  1905,  when  the  first  great  epidemic  occurred,  several  small 
groups  of  diseases  were  recorded  in  widely  separated  localities,  as,  for  in- 
stance, that  recorded  in  Louisiana  in  1841,  and  those  reported  in  England 
in  1843,  and  in  France  in  1868,  but  from  the  earliest  recognition  of  the 
affection  until  recently,  Scandinavia  has  furnished  a  large  majority  of  the 
recorded  epidemics,  and  also  of  isolated  cases.  The  first  epidemic  of 
poliomyelitis  in  Sweden  to  be  recorded  was  that  reported  by  Bergenholtz 
in  1881.  The  most  celebrated  were  those  which  occurred  in  1887  and  1895 
in  Stockholm,  and  described  by  Medin,  and  the  great  epidemic  of  1905 
fully  reported  by  Wickman  in  Sweden  and  by  Leegaard  in  Norway. 


94 

Accompanying  this  review  will  be  found  in  the  appendix  a  table  (No. 
1)  compiled  from  various  sources,  which  gives  in  condensed  form  the  date 
of  occurrence,  locality,  topography  and  distribution,  number  of  cases,  mor- 
tality, evidence  of  infection  and  transmission,  age  and  sex  incidence,  etc., 
together  with  special  annotations  and  references,  of  all  epidemics  recorded 
previous  to  1916. 

Observed  Epidemic  Features. 

The  following  features  have  been  observed  in  past  recorded  epidemics 
of  poliomyelitis  and  are  apparently  characteristic  of  the  disease : 

1.     Seasonal  Prevalence — 

Almost  without  exception  the  warm  season  of  the  year  has  been 
reported  as  the  period  of  the  greatest  prevalence  of  the  disease.  Usually 
beginning  to  attract  attention  in  June  or  July,  the  apex  of  the  epidemic 
has  been  reached  in  July  and  August.  One  great  epidemic,  namely  that 
occurring  in  Sweden  (1911)  had  two  high  periods,  one  early  and  the 
other  late  in  the  season,  October-December.  Some  epidemics  have  begun 
as  early  as  March  or  April  (Nebraska,  1909,  and  Iowa,  1910),  while  others 
did  not  get  under  way  until  August  or  September  (St.  Paul,  1909,  and 
Cincinnati,  1911). 

Since  the  preparation  of  the  report  of  the  New  York  City  epidemic  in 
1916,  the  following  information  has  been  received  through  correspondence 
with  Dr.  J.  B.  Weirich,  Director,  Division  of  Preventable  Diseases,  State 
Department  of  Health  of  West  Virginia : 

"  Between  December  10,  1916,  and  January  13,  1917,  an  epidemic 
with  74  cases  and  11  deaths  occurred  in  the  cities  of  Elkins,  Grafton 
and  Fairmont,  and  their  immediate  vicinities,  in  West  Virginia. 

"  The  weather  observations  for  December  and  January  for  this 
vicinity  are  as  follows : 

Maximum,  Minimum,  Mean, 

Deg.  F.  Deg.  F.  Deg.  F. 

December,  1916   44.3  20.5  32.4 

January,  1917   40.0  21.1  32.6." 

Complete  details,  with  full  epidemiological  data,  will  be  found  in  the 
forthcoming  report  of  the  Director  of  the  Division  of  Preventable  Diseases 
of  the  State  Department  of  Health  of  West  Virginia. 

Although,  as  a  rule,  whenever  the  disease  has  been  recognized,  isolated 
cases  have  been  reported  throughout  the  year,  its  epidemic  character  has 
almost  uniformly  disappeared  with  the  approach  of  cool  weather.  In  none 
of  the  epidemics  recorded  has  this  fact  been  satisfactorily  explained.  In 
certain  epidemics  it  was  thought  that  a  very  dry  and  dusty  season  was 
favorable  to  the  spread  of  the  disease,  but  comparison  of  meteorological 
data,  during  the  periods  of  epidemics  in  this  counrty  and  abroad,  shows 


95 

that  there  is  no  constant,  or  apparently  any  causal,  relationship  between  the 
dryness  or  wetness  of  seasons  and  the  prevalence  of  the  disease  either  in 
cities  or  in  rural  communities. 

2.  Topography — 

Until  recent  years  poliomyelitis  was  regarded  as  a  rural  disease,  and 
the  history  of  early  recorded  epidemics  apparently  substantiates  this  opinion. 
The  Scandinavians,  w^ho  from  long  experience  with  the  malady  may  be  sup- 
posed to  have  understood  it  well,  consider  it  entirely  of  rural  origin.  The 
Royal  Institute  of  Sweden,  in  a  report  to  the  Fifteenth  National  Congress 
on  Hygiene  and  Demography,  called  attention  to  the  "  endemic  continuance 
of  the  diseases  in  rural  rather  than  in  urban  districts,  while  epidemics  flare 
up  more  markedly  in  cities." 

The  following  table  shows  the  comparative  minor  incidence  of  polio- 
myelitis in  towns  in  Sweden : 

Epidemics  in  Sweden. 

Years    1905         1906        1907        1908        1909        1910        1911 

Cases    1016         429         467         317  178  109        3840 

Percentage   in  towns 7%  3%        23%         11%  87o  6%        19% 

3.  Distribution — 

Most  of  the  earlier  so-called  epidemics  comprised  only  a  few  cases 
scattered  among  a  comparatively  large  population.  Even  in  the  epidemic 
of  1905  and  1906  in  Norway  and  Sweden,  the  largest  up  to  that  date,  the 
cases  were  widely  disseminated,  although  small  separate  groups  often 
occurred. 

The  same  wide  distribution  of  cases  was  also  evidenced  in  the  epidemic 
of  1907  in  New  York  City.  In  Nebraska  in  1907  fifty-five  per  cent.  (55%) 
of  the  cases  developed  within  two  counties  containing  31,000  inhabitants, 
and  although  there  followed  other  groups  in  a  way  to  suggest  po'ssible 
sources  of  infection  of  one  group  from  the  other,  it  could  not  be  said  with 
any  degree  of  probability  that  the  foci  of  the  disease  had  a  common  origin. 
This  was  undoubtedly  the  case  in  New  York  City,  although  an  effort  was 
made  at  the  time  to  hold  it  responsible  for  the  subsequent  Western  out- 
breaks. It  is  true,  in  like  manner,  of  the  Minnesota  and  California  out- 
breaks of  the  same  and  following  years.  No  other  facts  were  established 
in  the  German  epidemic  of  1909,  and  in  the  Washington  outbreak  of  1910. 
One  important  observation,  however,  has  been  made  from  the  study  of  the 
distribution  of  cases  in  various  epidemics,  such  as  those  in  Scandinavia  and 
California,  in  Massachusetts  and  elsewhere,  namely,  that  when  the  disease 
repeated  itself  in  successive  years,  the  epidemic  of  the  next  following  year 
seemed  to  spare  the  areas  of  greatest  prevalence  of  the  preceding  years. 

The  almost  world-wide  extent  of  the  malady  is  evident  from  a  glance 
at  the  accompanying  table  (appendix  Table  No.  1),  which  includes  nearly 
every  European  country,  besides  showing  epidemics  in  North  and  South 


96 

America,  in  Australia,  the  West  Indies  and  in  the  South  Sea  Islands.  No 
portion  of  the  globe  has  thus  been  exempt  from  the  disease,  except  perhaps 
Asia  and  Africa,  from  which  no  cases  have  so  far  been  reported. 

4.  Number  of  Cases — 

The  cases  recorded  have  usually  been  .so  scattered  that  it  seemed 
futile  to  attempt  to  estimate  their  ratio  to  the  population,  but  whenever 
the  article  consulted  gave  actual  figures,  these  have  been  incorporated  in 
the  table  under  "  special  annotations."  The  total  number  of  cases  reported, 
however,  indicates  the  constantly  increasing  prevalence  of  the  disease. 

5.  Mortality —  '  • 

The  death  rate  for  poliomyelitis  has  varied  from  very  low,  in  most  of 
the  small  or  isolated  epidemics,  to  from  twenty  to  twenty-five  per  cent,  in 
the  larger  epidemics  in  the  United  States.  Since  a  greater  proportion  of 
the  severe  cases  have  evidently  been  recorded,  while  many  of  the  milder 
cases  have  probably  been  missed  altogether,  these  figures  must  be  consid- 
ered as  approximate  only. 

6.  Age  Incidence — 

As  a  rule,  the  majority  of  cases  in  the  epidemics  recorded  have  been 
among  infants,  ninety  per  cent,  having  been  under  ten  years  of  age.  In 
Norway  in  1868  fourteen  per  cent,  were  adults.  In  the  Iowa  epidemic  of 
1910,  over  twelve  per  cent,  of  those  affected  were  adults,  among  whom  the 
death  rate  was  high.  In  Norway,  again,  in  1911,  the  adult  case  rate  was 
remarkably  high,  namely  twenty-five  per  cent,  of  all  cases  reported.  From 
this  it  would  appear  that,  although  there  has  been  a  relatively  greater  inci- 
dence among  persons  under  twenty  years  of  age,  and  a  smaller  incidence 
among  the  adult  population,  older  children  and  adults  have  not  always 
escaped. 

7.  Race  and  Sex — 

No  racial  susceptibility  or  immunity  to  the  disease  has  been  recorded, 
although,  in  certain  epidemics,  one  or  other  racial  group  may  have  apparently 
shown  at  times  a  somewhat  restricted  incidence. 

As  to  sex,  the  proportion  of  males  to  females  has  averaged  three  to 
two,  in  recorded  past  epidemics ;  no  explanation  is  given  of  this  discrepancy, 
but  a  similar  observation  as  to  sex  has  also  been  made  in  other  diseases. 

8.  Relation  to  Domestic  Animals — 

This  factor,  so  often  referred  to  in  the  reports,  may  be  summarized 
by  the  following  quotation  from  Frost  (Hyg.  Lab.  Bui.  No.  90)  : 

It  has  frequently  been  suggested  that  domestic  animals  may  play 
an  important  part  in  the  spread  of  poliomyelitis.  This  suggestion  is 
based  chiefly  upon  the  observations  during  epidemics  of  paralytic 
affections  of  various  animals :  dogs,  cats,  horses,  cattle,  swine,  rabbits, 


97 

and  fowls.  So  far  no  evidence  has  been  adduced  to  show  that  these 
paralytic  af^"ections  are  etiologically  related  to  human  poliomyelitis, 
and  considering  that  various  paralytic  affections  are  rather  common, 
it  may  well  be  that  the  frequency  with  which  such  instances  have 
been  observed  during  human  epidemics  of  poliomyelitis  is  attributable 
largely  to  the  increased  interest  which  they  excite  at  such  times." 

9.     Contact  Infection — 

Inasmuch  as  the  earlier  epidemics  were  usually  small  and  not  well 
studied,  practically  the  only  information  available  regarding  this  point  is  the 
frequency  with  which  more  than  one  case  developed  in  a  family  or  house- 
hold. Holt,  who  searched  the  literature  of  thirty-five  epidemics  occurring 
prior  to  1908,  could  find  but  forty  such  instances  comprising  ninety-six  cases. 

Gundrum,  in  reporting  the  California  epidemics  of  1910,  1911  and 
1912,  found  that  four  per  cent.,  three  per  cent,  and  eight  per  cent,  of  the 
respective  years  might  be  considered  contact  cases. 

Dixon,  in  reporting  the  Pennsylvania  epidemic  of  1910,  comprising 
1,076  cases,  claimed  that  six  per  cent,  were  contacts. 

Harbitz  (J.  A.  M.  A..  Sept.  7,  1912).  says  that  "the  conclusion  of  the 
Norwegian  physicians  is  that  poliomyelitis  is  an  acute  infectious  disease 
which  must  be  considered  directly  communicable  from  one  person  to  an- 
other.'' He  states  that  "  in  the  study  of  virulent  house  epidemics,  it  was 
also  found  that  one  member  of  the  family  after  the  other  became  infected, 
with  a  few  days  intermission,  and  that  they  would  exhibit  the  disease  in  its 
different  forms."  He  gives  several  illustrative  cases  which  apparently  con- 
firm this  statement. 

In  the  English  epidemic  of  1911,  some  one  in  nearly  every  household  in 
a  small  hamlet  in  Devonshire  became  ill  with  what  seemed  to  be  an  abortive 
attack.  Only  one  or  two  developed  paralysis.  In  the  ^Massachusetts  epi- 
demic of  1908,  among  sixty-seven  families  in  which  single  cases  occurred. 
there  were  one  hundred  sixty-six  children,  but  only  two  later  or  secondary 
cases.  In  the  Nebraska  epidemic  ri909).  among  forty-one  families  in  which 
there  were  one  hundred  fifty-six  children,  there  occurred  eighty-six  cases. 
In  the  Pennsylvania  epidemic  (1910),  two  hundred  eighty-nine  children 
slept  in  the  same  rooms  with  paralytic  cases,  but  only  twenty-four  contracted 
the  disease.  In  the  Iowa  epidemic  (1910),  among  twelve  families  comprising 
seventy  persons,  and  furnishing  the  entire  attendance  of  a  small  county 
school,  there  occurred  only  five  paralytic  and  probably  eighteen  abortive 
cases. 

From  an  investigation  of  the  Iowa  epidemic  of  1910,  of  that  in  Cin- 
cinnati in  1911,  and  of  that  in  Buft'alo  in  1912,  Frost  (Hyg.  Lab.  Bui.  No. 
90)  found  105  cases  (23.17^),  giving  histories  of  contact,  certain  or 
probable,  direct  or  indirect,  with  previous  paralyzed  abortive  or  indefinite 
suspected  cases,  and  348  cases  (76.83%),  giving  no  history  of  any  contact 
with  any  previous  case. 

It  is  evident,  therefore,  he  says,  '''  that  contact  with  previous  recognized 


98 

or  even  suspected  cases  of  poliomyelitis  was  not  established  in  one-fourth 
of  the  cases  investigated ;  that  while  it  is  true  that  in  the  above  figures  here 
is  probably  a  cerain  error  due  to  failure  to  elicit  histories  of  contact  in  some 
cases  where  it  had  actually  taken  place,  it  is  most  probable  that  any  such 
error  would  be  counterbalanced  by  the  inclusion  of  some  cases  in  which  the 
history  of  contact  was  not  altogether  evident." 

In  a  study  of  the  contagiousness  of  the  same  epidemics,  from  the  point 
of  view  of  the  incidence  of  the  disease  among  persons  known  to  have  had 
intimate  contact  with  acute  casgs,  Frost  states  that  the  apparent  con- 
tagiousness of  poliomyelitis  is  considerably  less  than  that  of  diphtheria  or 
scarlet  fever,  even  when  clinically  doubtful  cases  are  included.  Neverthe- 
less, he  concludes  that  none  of  the  factors  that  are  usually  considered  in  the 
spread  of  an  infection,  other  than  personal  contact,  seems  to  offer  an  ade- 
quate explanation  of  the  origin  and  spread  of  the  epidemic,  although  further 
and  more  clinical  study  of  the  disease  is  undoubtedly  essential  to  a  clear 
understanding  of  its  epidemiology. 

10.  Persistence  of  Infection — 

The  Royal  Medical  Institute  of  Sweden  states  that  during  the  great 
epidemic  of  1911,  experiments  demonstrated  that  infection  persisted  in  the 
mouth  and  in  the  intestinal  tract  of  some  convalescents  for  long  periods  of 
time,  namely,  from  a  few  (two  or  three)  weeks  to  several  (four  to  seven) 
months,  after  onset  of  the  malady.  These  experiments  were  made  from  both 
mouth  and  intestinal  waskings,  and  the  virulence  tested  by  intra-peritoneal 
injections  in  monkeys. 

11.  Fomites — 

In  connection  with  the  same  epidemic,  Josefson  states  that  the  infection 
apparently  adhered  to  handkerchiefs  and  other  recently  handled  articles,  and 
remained  virulent  for  several  days. 

12.  Food  and  Milk — 

It  does  not  appear  from  the  records  that  food  has  had  any  definite  re- 
lation to  the  spread  of  the  disease.  As  the  result  of  his  study  of  the  Iowa 
epidemic,  Frost  states  that  infection  from  a  common  food  or  water  supply 
could  be  readily  eliminated,  as  the  source  of  these  supplies  was  so  various ; 
that  food  supplies  which  ordinarily  fall  under  suspicion,  namely,  dairy  pro- 
ducts, fruits  and  uncooked  vegetables,  were,  in  the  great  majority  of  cases, 
obtained  by  each  patient  on  his  own  premises ;  that  even  staple  groceries  of 
the  affected  families  were  obtained  from  various  sources ;  and  that  the  possi- 
bility of  infection  having  been  contracted  and  spread  through  ice  cream, 
soda  water,  etc.,  at  some  common  source  could  also  be  eliminated. 

In  the  study  of  various  other  epidemics,  the  question  as  to  the  milk 
supply  as  a  possible  source  of  infection  has  been  especially  considered,  but 
it  was  usually  agreed  that  unless  a  great  many  different  foci  of  infection 


99 

existed  the  evidence  did  not  seem  to  point  that  way.  Since  the  main  inci- 
dence of  the  malady  has  been  largely  among  the  milk-fed  portion  of  the 
community,  it  is  only  natural  that  milk  should  have  been  suspected  of  being 
in  some  manner  involved,  and  it  was  recognized  that  this  food  might  act 
in  two  ways :  it  might  convey  infection  directly,  or  it  might,  during  the  pro- 
cess of  digestion,  aid  more  than  any  other  kind  of  food  in  the  development 
of  the  virus  within  the  body. 

In  this  connection,  the  question  as  to  the  relative  prevalence  of  the 
disease  among  nurslings  is  interesting,  since  those  that  contracted  polio- 
myelitis who  were  fed  exclusively  upon  mothers'  milk  could  be  definitely 
stated  not  to  have  received  their  infection  through  cow's  milk.  The  records 
on  this  point,  however,  as  given  in  the  history  of  past  epidemics,  are  not 
sufficient  to  be  of  much  value.  The  following  include  all  the  data  that  could 
be  found: 

Epidemics.  Year.  Status  of  Cases  Regarding  Breast  Feeding. 

New   York    1907      "121  cases  exclusively  breast-fed  out  of  283  infants 

under  2  years." 

Massachusetts    1907      "None    of   seven   cases    under     1    year   exclusively 

breast-fed." 

Westphal,  Germany  ....  1909  "Considerable  number  of  breast-fed  children  af- 
fected." 

Massachusetts    1909      "  No  cases  exclusively  breast-fed." 

Iowa    1910      "  Two     cases     exclusively     breast-fed     out     of     47 

studied." 

Cincinnati    1911       "15  cases  exclusively  breast-fed  out  of  83  studied." 

Buffalo 1912      "12  cases  exclusively  breast-fed  out  of  40  studied." 

13.  Place  Infection —    , 

The  widespread  distribution  of  cases  would  seem  to  indicate  that  if 
place  infection,  as  by  means  of  dust,  etc.,  was  operative  at  all,  it  must  have 
been  through  numerous  foci  having  apparently  no  relation  to  one  another. 

14.  Insects  as  Garners — 

Although  several  kinds  of  insects,  e.g.,  flies,  bed  bugs,  fleas,  and  the 
like,  have  been  occasionally  suspected  of  acting  as  mechanical  carriers  of 
poliomyelitis,  no  particular  insect  has  been  positively  incriminated.  In  any 
event,  there  has  been  no  indication  from  the  history  of  past  epidemics  that 
insects  played  any  important  part  in  the  spread  of  the  disease. 

Poliomyelitis  in  New  York  State  and  City  in  the  Past. 

There  are  no  available  statistics  as  to  the  prevalence  of  poliomyelitis 
in  either  the  State  or  City  of  New  York  prior  to  1907,  when  the  first  con- 
siderable epidemic  occurred.  Some  indication,  however,  of  the  number  of 
sporadic  cases  is  given  by  the  following  list*  of  cases  applying  to  the  clinic 

*  Bogardus,  in  discussion  of  paper  by  Bowden,  J.  M.  S.  of  N.  J. — 1908. 


100 

of  the  New  York  Orthopedic  Hospital  for  treatment  of  the  sequelae  of  in- 
fantile paralysis  during  the  ten  years  preceding  1907: 

Years.  Cases. 

1897    79 

1898    65 

1899    78 

1900    56 

1901    98 

1902    110 

1903    108 

1904    90 

1905    82 

1906 106 

1907    215 

■  Epidemic  of  Poliomyelitis  in  New  York  City  in  1907. 

In  1907,  New  York  City  suffered  an  extensive  outbreak  of  poliomyeli- 
tis. The  statistics  of  this  epidemic  are  very  incomplete.  Owing  to  the  in- 
clusion of  poliomyelitis  in  the  mortality  returns  with  "  other  diseases  of  the 
nervous  system,"  the  exact  number  of  deaths  from  the  malady  is  not  avail- 
able, and  even  the  number  of  cases  reported  as  occurring  within  the  city, 
is  largely  based  upon  guess  work.  Whether  the  infection  was  directly  im- 
ported from  Europe,  as  many  seem  to  have  thought,  or  whether  it  followed 
the  Scandinavian  theory  of  endemic  rural  foci  overflowing  into  the  city,  is 
unknown,  and  no  reliable  evidence  on  the  subject  is  available;  but  it  would 
appear  from  the  list  of  cases  given  above,  which  occurred  annually  in  New 
York  previous  to  1907,  that  poliomyelitis  has  long  been  endemic  in  the  City. 

The  Committee*  which  investigated  the  1907  outbreak  obtained  posi- 
tive information  concerning  eight  hundred  (800)  cases  only,  although  it  was 
estimated  that  two  thousand  five  hundred  (2,500)  cases  had  occurred.  These 
eight  hundred  cases  were  carefully  mapped  and  studied,  and  the  results  in- 
dicated a  distribution  approximately  proportionate  to  the  density  of  the 
population.  To  this  there  was  one  exception,  namely,  on  the  lower  east 
side  of  Manhattan  where  more  cases  in  proportion  occurred  than  elsewhere. 
The  following  list  gives  the  number  of  cases  of  poliomyelitis  occurring  in 
New  York  City  in  1907  in  which  details  of  onset  were  known : 

Month.                                           Cases.  Month.  Cases. 

January 5  July    133 

February    3  August    188 

March    4  September     218 

April    3  October    71 

May    10  November    20 

June 59  December    4 

Total — 718  cases. 


*  The  collective  investgation  committee  of  the  poliomyelitis  epidemic  of  1907  was 
composed  of  representatives  of  the  New  York  Neurological  Society,  the  Pediatric 
Section  of  the  New  York  Academy  of  Medicine,  the  Rockefeller  Institute  of  Medical 
Research,  and  the  Health  Department  of  New  York  City. 


lUl 

The  virulence  of  this  epidemic  seems  to  have  been  very  mild  when 
compared  with  that  manifested  in  other  large  groups  of  cases  elsewhere, 
and  this  is  true  even  when  a  comparison  is  made  with  urban  epidemics  only. 
The  Committee  estimated  the  death  rate  to  be  five  per  cent.,  and  when  we 
compare  this  mortality  with  that  of  the  usual  European  epidemics  in  cities, 
namely,  ten  per  cent.,  and  consider  the  mortality  reported  of  the  Buffalo 
outbreak  in  1912,  twenty-one  per  cent.,  together  with  that  recorded  in  the 
recent  epidemic  of  1916,  twenty-six  plus  per  cent.,  we  realize  how  very  mild, 
apparently,  was  the  virulence  of  the  1907  epidemic. 

The  age,  race  and  sex  incidence  of  the  disease  in  1907,  was  found  to 
correspond  with  that  recorded  in  mo'st  of  the  epidemics  elsewhere,  viz.,  that 
though  no  age,  sex,  or  race  was  exempt,  the  incidence  was  greater  among 
young  children  than  other  children  and  adults,  and  greater  among  males 
than  females. 

From  a  study  of  the  family  incidence  of  cases,  the  Committee  made 
the  following  observations  regarding  the  communicability  of  the  disease : 

Out  of  2,000  children  in  seven  hundred  sixty-two  (762)  families,  who 
were  reported  as  having  been  exposed  to  the  infection,  eighteen  instances 
were  encountered  in  which  two  cases  occurred  in  the  same  family ;  in  two 
instances  three  cases  occurred  in  the  same  family ;  in  very  few  instances 
did  more  than  one  case  occur  in  a  household. 

There  was  no  evidence  that  the  schools  had  anything  to  do  with  the 
spread  of  the  malady,  as  they  were  closed  during  the  period  of  extensive 
prevalence. 

Regarding  the  incubation  period,  the  results,  though  not  conclusive,  in- 
dicated that  it  was,  approximately,  from  three  to  seven  days. 


CHAPTER    IV. 
Epidemiology  (Continued). 

1.     Poliomyelitis  in  New  York  City  in  1916. 

With  the  hope  of  solving  certain  problems  which  have  so  far  remained 
doubtful,  the  Department  of  Health  has  made  an  epidemiological  study 
of  the  1916  outbreak.  Although  the  results  obtained  have  been  inconclusive 
regarding  some  of  the  points  which  await  complete  elucidation,  new  features 
of  interest  have  been  brought  to  light  during  the  recent  epidemic,  while 
others,  partially  established,  have  been  positively  confirmed.  The  following 
data  are  taken  from  the  official  reports  and  records: 

Season — 

Deaths  from  poliomyelitis  as  recorded  each  month  for  the  past  five 
years  (1912-1916)  occurred  sporadically  throughout  each  year,  but  the 
mortality  was  highest  each  year  during  the  months  of  July,  August,  Sep- 
tember and  October — in  other  words,  during  the  warm  season. 

From  1912  to  1915,  inclusive,  there  was  a  gradual  decrease  in  the 
number  of  deaths  reported  from  this  disease. 

In  1916,  the  mortality  averaged  the  usual  rate  until  June,  when  it  began 
to  rise.  This  rise  continued  until  the  first  week  in  August,  when  it 
reached  its  maximum,  and  thereafter  commenced  to  decline. 

It  is  to  be  noted,  according  to  these  statistics,  that  poliomyelitis  in 
New  York  City  is  a  disease  of  the  warmer  months,  even  when  it  is  not 
epidemic.     (See  table  II  in  the  appendix.) 

Onset — 

From  May  12,  1916,  sporadic  cases  of  poliomyelitis  were  reported,  but 
not  until  June  did  the  reported  cases  become  sufficiently  numerous  to  attract 
attention,  and  then  only  in  the  Borough  of  Brooklyn.  During  the  succeed- 
ing weeks,  in  this  borough,  the  number  of  cases  reported  rose  steadily. 
During  June,  in  the  Borough  of  Manhattan,  several  cases  were  reported, 
but  not  until  the  first  week  of  July  did  the  reported  cases  become  sufficiently 
numerous  to  warrant  the  statement  that  the  epidemic  had  found  its  way 
to  the  most  thickly  populated  borough  of  the  City.  During  the  last  few 
days  of  June,  cases  also  began  to  appear  in  the  Boroughs  of  Queens  and 
Richmond. 

On  July  11th,  in  the  Borough  of  Brooklyn,  one  hundred  fifty-one  (151) 
cases  were  reported,  the  largest  number  reported  on  any  one  day  in  this 
Borough  during  the  epidemic.  On  or  about  July  19th,  the  maximum  was 
reached  in  the  Borough  of  Richmond ;  in  the  Borough  of  Queens,  the  crisis 
of  the  epidemic  was  reached  on  or  about  August  6th,  and  in  Manhattan 
rnd  The  Bronx,  on  or  about  August  12th. 


103 

The  outstanding  fact  to  be  noted  from  these  records  is,  that  during 
i\Tay  and  the  first  ten  days  in  June,  one  hundred  eight  (108)  cases  of 
pohomyeHtis  had  their  onset,  but  only  fifteen  (15)  of  these  were  reported 
during  this  period,  and  four  only  prior  to  June  3d.  In  other  words,  there 
were  ninety-three  (93)  foci  of  infection  spreading  the  disease  between 
May  1st  and  June  10th,  which  were  not  reported  and  constituted  a  serious 
menace  to  the  pubhc,  as  no  measures  of  isolation  were  employed.  (See 
table  III  in  the  appendix.) 

Course — 

The  course  of  the  epidemic  is  best  shown  by  a  tabulation  of  cases  by 
week  of  onset. 

Cases  of  Poliomyelitis  by  Week  of  Onset. 


Week  Ending  ^^lanhattan    The  Bronx     Brooklyn         Queens       Richmond        City 

June    3 5  1  25  1  1  ZZ 

Tune   10 8  0  39  0  2  49 

June   17 6  0  84  1  8  99 

June  24 17  3  204  4  5  233 

July     1 50  8  351  8  28  445 

July    8 118  26  491  52  29  716 

July   15 119  29  466  99  46  759 

July  22 192  54  482  117  54  899 

July  29 305  47  538  145  41  1,076 

Aug.    5 318  82  573  218  15  1,206 

Aug.  12 325  90  345  150  25  935 

Aug.  19 293  85  250     '  119  12  759 

Aug.  26 226  52  151  72  4  505 

Sept.    2 173  61  87  38  8  Z67 

Sept.     9 104  34  68  28  4  238 

Sept.  16 91  35  45  20  0  191 

Sept.  23 59  30  31  17  2  139 

Sept.  30 46  23  25  8  3  105 

Oct.     7 38  27  8  13  0  86 

Oct.    14 16  8  10  7  0  41 

Oct.   21 17  7  4  5  0  33 

Oct.   28 14  2  5  3  0  24 

Nov.    4 6  4  1  3  0  14 

Nov.  11 4  0  1  0  0  5 

Nov.  18 3  1  2  -  0  0  6 


These  figures  present  several  interesting  epidemiological  points.  We 
have,  in  each  of  the  five  boroughs  of  the  city,  an  example  of  the  typical 
course  of  the  epidemic  covering  a  period  of  time  from  four  to  six  months, 
the  number  of  cases  rising  steadily  until  about  the  middle  period,  when  it 
steadily  declines. 

Under  the  same  conditions  of  temperature,  rainfall,  humidity,  cloudi- 
ness, sunshine,  wind,  dust,  etc.,  we  find  the  outbreak  progressing  in  one 
part  of  the  city  and  subsiding  in  another. 

In  the  Boroughs  of  Brooklyn  and  Queens,  the  epidemic  starting  about 
the  same  time  reaches  its  maximum  in  the  same  week,  then  begins  to 
decline.  In  Manhattan  and  the  Bronx,  also  starting  near  together,  it 
reaches  its  maximum  in  the  week  following  the  Brooklyn  and  Queens  maxi- 


104 

mum.     In  the  Borough  of  Richmond,  on  the  other  hand,  starting  later  than 
the  others,  it  reaches  its  maximum  two  weeks  earher. 

That  the  course  of  the  epidemic  was  not  materially  modified  by  weather 
conditions  is  clearly  shown  in  table  IV  in  the  Appendix. 

These  facts  are  further  confirmed  by  the  following  tabulation  of  fatal 
cases  by  weeks  of  onset  of  the  disease,  in  the  various  boroughs  and  the 
city : 

Deaths  from  Poliomyelitis  by   Weeks  of  Onset  of  Disease. 

Week  Ending         Manhattan     The  Bronx     Brooklyn        Queens  Richmond  City 

June    3 1                     0                     0                     0  0  1 

June  10 0                     0                     4                     0  0  4 

June  17 0                    0                   14                    0  2  16 

June  24 7                     0                   47                     0  0  54 

July      1 9                     2                   9S                     4  6  119 

July     8 18                    8                 123                   17  4  170 

July    15 30                   12                  135                   28  9  214 

July   22 60                   14                  130                   37  14  255 

July   29 85                    9                 148                  41  6  289 

Aug.    5 92                   17                 186                  74  5  374 

Aug.  12 103                   17                  86                  40  5  251 

Aug.  19 88                  21                  65                   31  2  207 

Aug.  26 69                   11                   44                  20  1  145 

Sept.    2 38                   14                  34                   10  2  98 

Sept.    9 35                    5                   13                    8  2  63 

Sept.  16 23                   10                  13                    ^  ^  51 

Sept.  23 21                    8                    6                    8  0.  43 

Sept.  30 12                    6                    5                    4  0  27 

Oct.     7 .9                   6                   3                   4  0  22 

Oct.    14 -4                    3                    3                    1  S  ^1 

Oct.   21 4                    3                    10  0  8 

Oct.   28 5                     1                     1                     1  0-8 

Nov.    4 2                    10                    10  4 

Nov.  11 10                    0                    0  0  1 

Nov.  18 


Case  Fatality — 

From  the  number  of  cases  reported  by  weeks  of  onset,  and  that  of 
deaths  by  weeks  of  actual  occurrence,  it  appears  that  in  the  fatal  cases 
many  deaths  did  not  occur  in  the  first  week  of  the  disease,  but  only  after  the 
disease  had  lasted  for  several  weeks,  thus  causing  an  accumulation  of  deaths 
reported  in  the  later  weeks.  This  is  shown  in  Table  III  in  the  appendix. 
On  hastily  glancing  at  this  table,  the  impression  may  be  conveyed  that  the 
case  fatality  was  a  steadily  increasing  one  as  the  epidemic  spread,  but  this 
is  erroneous ;  the  case  fatality  was  more  or  less  a  constant  quantity  through- 
out the  epidemic,  as  is  clearly  shown  by  referring  to  Table  V  in  the 
Appendix. 

This  table  (No.  V)  shows  the  mortality  as  it  prevailed  in  over  eight 
thousand  eight  hundred  (8,800)  cases  followed  to  their  termination;  the 
deaths  occurring  i«  these  cases  being  distributed,  not  according  to  the  weeks 


105 

in  which  the  deaths  occurred,  but  by  the  weeks  of  onset.  The  figures  for 
the  first  three,  weeks  should  not  be  considered,  as  the  cases  represented  in 
these  weeks  are  not  those  that  were  reported  to  the  Department  at  the 
time  of  their  occurrence,  but  were  those  that  were  subsequently  found  as 
a  result  of  the  investigation  made  by  the  Department  physicians.  As  some 
of  the  deaths  among  these  cases  were  attributed  to  other  causes,  it  is 
probable  that  the  number  of  deaths  from  poliomyelitis,  during  these  weeks, 
were  under-estimated.  It  is  well  to  know  that  the  deaths  as  reported  in 
those  three  weeks  numbered  only  six,  and  the  addition  of  a  few  deaths 
would  bring  the  case  fatility,  in  those  weeks,  up  to  a  figure  comparable 
with  those  of  the  following  weeks.  It  Avill  be  noted  that,  during  the  weeks 
from  June  24  to  October  14,  there  was  no  great  variation  in  the  case  fatality ; 
in  most  of  the  weeks  the  ratios  of  deaths  to  cases  occurring  were  approx- 
imately 26,  27  or  28  per  cent.  In  only  two  instances  did  the  rate  go  as 
high  as  31  per  cent.  It  is  evident,  therefore,  that  there  was  no  increasing 
fatality  as  the  disease  progressed,  and  that  a  fairly  constant  ratio  between 
cases  and  deaths  was  maintained  throughout  the  epidemic. 

The  following  table  shows  the  duration  of  the  disease  before  death  in 
1848  fatal  cases  occurring  before  August  31st  and  made  the  subject  of 
immediate  study : 

Deaths  of  Poliomyelitis  by  Day   of  Illness. 


Day  of  Illness.  Deaths.          By  Weeks. 

1st 55 

2d 179 

3d 315 

4th 369 

5th 300 

6th 182 

7th 110         1st  Week,  1,510 

8th 67 

9th 41 

10th 36 

11th 28 

12th 16 

13th 15 

14th 8         2d  Week,      211 

15th 11 

16th 15 

17th 8 

18th 6 

19th 5 

20th 10 

21st 5         3d  Week, 

Later 67 


Per  Cent. 


81.7-t- 


11.4-1- 


60 
67 


1,848 


3.2-1- 
3.6  + 


The  course   of  the   epidemic   may  also  be   illustrated  graphically  by 
curves,  showing  the  occurrence  of  cases  on  day  of  onset  and  deaths  on 


106 

day  of  death,  for  the  months  of  July,  August,  September  and  October. 
(See  Chart  I,  frontispiece.) 

With  the  exception  of  the  nurslings,  that  is  children  under  one  year  of 
age  in  whom  death  was  in  no  inconsiderable  number  due  to  the  difficulties 
of  nutrition  (partly  caused  by  the  muscular  paralysis  and  partly  due  to  the 
severity  of  the  general  infection)  almost  all  of  the  deaths  that  occurred  in 
the  first  week  of  the  disease,  and  the  great  majority  of  those  that  occurred 
in  the  second  week,  were  due  to  definite  and  easily  observed  respiratory 
paralysis. 

From  the  second  week  onward,  the  deaths  which  occurred  were  in  a 
progressively  smaller  proportion  of  cases,  due  to  respiratory  paralysis,  and 
we  find  in  the  third  week  and  later,  an  increasing  number  of  deaths  from 
cardiac  failure,  from  secondary  pneumonia  and  from  the  late  results  of 
complicating  gastro-enteritis. 

The  deaths  from  cardiac  failure  in  almost  all  instances  followed  a 
prolonged  period  of  persistent  rapid  pulse  rate,  the  fatal  issue  following 
immediately  upon  what  was  noted  as  fibrillation  of  the  heart,  with  rapidly 
developing  or  increasing  dyspnoea  and  cyanosis.  It  must  be  left  for  further 
clinical  and  pathological  study  to  determine  whether  this  cardiac  failure  is 
due  more  to  myocarditis,  originally  resulting  from  the  fever  and  general 
infection  of  the  disease,  or  whether,  in  some  instances,  it  follows  a  possible 
late  extension  of  the  spinal  lesion  involving  the  bulbar  centres. 

Deaths  after  the  third  week  were  much  more  commonly  due  to  secon- 
dary and  complicating  broncho-pneumonia  or  gastro-enteritis,  broncho- 
pneumonia being  particularly  rapid  in  its  extension  and  fatal  issue  in  such 
cases  as  had  extensive  primary  paralysis  of  the  four  extremities,  with  more 
or  less  intercostal  paralysis.  The  clinical  pictures  presented  by  those  who 
died  with  serious  nutritional  disturbances  were  similar  to  those  commonly 
observed  in  cases  of  prolonged  hydrocephalus  and  tuberculous  meningitis. 

Sex  and  Age — 

From  a  study  of  the  death  statistics  tabulated  according  to  sex  and 
age,  it  is  evident  that  the  mortality  of  the  disease  was  heavier  among  males 
than  females  and  among  young  children  than  older  children  and  adults.  A 
similar  preponderance  of  males  over  females  and  young  children  over 
older  children  and  adults  is  found  in  the  incidence  of  the  disease.  (See 
table  IV  in  the  appendix,  which  gives  the  cases  at  each  age  group  from  June 
1st  to  November  1st,  1916.) 

The  following  additional  facts  are  well  shown  graphically  in  the  chart 
(No.  1)  attached  to  the  Appendix,  namely,  that  the  mortality  was  greatest 
in  the  second  year  of  life;  that  the  mortality  of  the  female  was  higher 
than  the  mortality  of  the  male,  in  the  sixth  year  of  life;  that  in  the  second 
year  of  life,  i.  e.,  between  the  twelfth  and  twenty-fourth  month,  almost 
22%  of  the  total  number  of  deaths  occurred;  that  practically  79%  of  the 
mortality  of  poliomyelitis,  in  this  epidemic,  occurred  in  the  first  five  years 


107 

of  life;  and  that  after  the  fifth  year,  there  was  a  steady  decline  in  the 
mortality  of  the  disease.  What  has  been  said  as  to  the  mortality  of  polio- 
myelitis likewise  applies  to  the  incidence  of  the  disease,  the  greatest  number 
of  cases  occurring  in  the  second  and  third  years  of  life.  (See  able  IV 
in  the  Appendix.) 

The  following  table  gives  the  results  of  a  study  of  the  ages  of  1,325 
fatal  cases. 

Ages  in  Teryns  of  Percentage. 

Under  1       year  13% 

1+  year  22% 

2+  years  18% 

Z-\'  years  14% 

4+  years  9fo 
83%  were  5  years  and  under 

5+  years  7% 

6-j-  years  5% 

7-\-  years  3% 

8+  years  2% 

9+  years  1.5% 
15%  were  from  6-16  years 

10-|-  years  .757o 

11+  years  .375% 

12-|-  years  .375% 

13-(-  years  .75% 

144-  years  .375% 

15-|-  years  .375% 

Xo.   cases   under   16  years  97.5% 

Over  16  years  2.5% 

During  the  past  epidemic,  while  testing  by  the  Schick  reaction  the 
children  suffering  from  poliomyelitis  who  were  admitted  to  the  Willard 
Parker  Hospital,  a  very  interesting  fact  was  established  which  may  have 
some  bearing  on  the  question  of  natural  immunity.  Of  1,350  children 
tested  there  were  between  one  and  four  years  of  age  954,  and  of  these  774, 
or  over  81%,  showed  a  positive  Schick  reaction.  It  was  very  striking 
indeed  to  see  in  the  wards  row  after  row  of  children  who  gave  a  positive 
reaction.  At  one  time,  the  number  of  positive  tests  in  this  group  in  the 
hospital  reached  between  90  and  95  per  cent.  In  normal  children  of  the 
same  age  group,  the  positive  Schick  tests  vary  from  30  to  40  per  cent ;  in 
measles  the  percentage  of  positive  tests  is  somewhat  similar ;  while  in 
scarlet  fever  it  is  about  60  to  65  per  cent.  Considering  the  relatively  mild 
infectiousness  of  poliomyelitis  (according  to  Frost  1/15  as  infectious  as 
scarlet  fever),  a  fair  conclusion  to  be  drawn  from  these  results  would  seem 
to  be  that  a  susceptibility  to  one  of  the  less  contagious  diseases  indicates  that 
the  child  is  also  more  apt  to  he  susceptible  to  other  contagious  and  infectious 
diseases. 

Nationality — 

■Records  have  been  kept  of  the  deaths  from  poliomyelitis  according  to 
the  nationality  or  nativity  of  the  parents.  The  number  of  parents  in  each 
nationality  was  estimated,  and  the  death  rate  of  the  children  of  each  nation- 


108 

ality  was  thus  computed.  It  was  found  that,  no  nationaUty  was  exempt. 
Only  among  the  children  of  Austro-Hungarians,  Germans,  Irish,  Italians, 
Russians,  Poles  and  Americans,  was  there  a  sufficient  number  of  deaths 
recorded  to  enable  a  comparison  to  be  drawn  between  them. 

In  descending  order,  the  death  rate  per  1000  estimated  population  of 
children  under  ten  years  of  age,  of  different  nationalities,  stands  as  follows : 

United  States    3 .42 

Germany    3 .  27 

Ireland    2 .  25 

Russia  and  Poland  1.71 

Austro-Hungary    1 .  67 

Italy    1.63 

From  these  records  it  would  appear  that  there  was  some  difference 
in  the  fatality  of  the  disease  amongst  children  of  different  stocks.  To 
what  this  difference  is  due  it  is  impossible  to  say.  It  is  noticeable,  however, 
that  the  mortality  of  the  Italians,  Austro-Hungarians,  Russians,  and  Poles 
is  the  lowest.  Certainly,  the  social  and  economic  conditions  under  which 
these  people  live  are  no  more  favorable  than  those  under  which 
the  Americans,  Germans  and  the  Irish  live,  among  whom  the  mortality  of 
the  disease  is  highest.     (See  Table  XIII  in  the  Appendix.) 

As  it  may  be  of  interest  from  a  sociological,  if  not  an  epidemiological, 
point  of  view,  to  know  what  nationalities  were  affected,  the  following  list 
of  cases  of  poliomyelitis  is  appended.  This  list  is  incomplete  as  to  the 
numerical  relation  of  the  different  nationalities  among  the  cases  of  polio- 
myelitis compared  with  each  other,  but  it  affords  a  rough  guide  as  to  the 
number  of  nationalities  affected  by  the  disease. 

Manhattan.  Bronx.  Brooklyn.  Queens.  Richmond.    City. 

Native  (Born  in  U.  S.  A.) 822  386  1873  583  161  3,825 

Italian    404  58  6^4  161  41  1.348 

Russian    494  79  685  25  4  1,287 

Irish    231  47  277  l(i  13  644 

Austrian    238  27  189  19  6  479 

German    82  48  189  144  16  479 

Polish    29  9  95  74  17  224 

Norwegian    6  . .  78  3  14  101 

English    21  8  60  21  8  118 

Hungarian 60  14  19  10  ..  103 

Roumanian   24  5  27  1  2  59 

Scotch    12  1  27  6  ..  46 

Swedish  9  3  55  8  . .  75 

Lithuanian 1  . .  13  .  .  . .  14 

West  Indian 15  ..  5  ..  ..  20 

French  6  1  7  3  ..  17 

Danish     1  1  7  =;  ..  14 

Canadian   10  1  5  3  1  20 

Bohemian 12  1  ..  5  ..  18 

Finn    5  5  10  5  1  26 

Syrian    1  1  6  1  ..  9 

Greek  14  ..  3  ..  ..  17 


109 


Manhattan.  Bronx.  Brooklyn.  Queens.  Richmond.    City. 


Swiss    

Spanish    

Dutch   

Turkish 

Cuban < 

Japanese    

Slavonian    

Belgian 

Porto  Rican  . . . . 

Portuguese   

Mexican    

African    

South  American 

Indian    

Armenian    

Ukarainian    

Serbian    


Total    2,540 


700 


4,326         1,154 


285 


14 
12 
5 
10 
6 
2 
2 


9,005 


Face — • 

Records  were  also  kept  of  the  incidence  and  mortality  of  poliomyelitis 
among  different  races.  Only  among  the  negro  race  were  there  a  sufficient 
number  of  cases  and  deaths  reported  to  be  able  to  compare  them  with  the 
white  race ;  and  these  are  too  few  to  draw  any  conclusions  from  them. 

In  comparing  the  incidence  of  poHomyelitis  among  whites  with  the 
incidence  among  negroes,  it  will  appear  that  the  negro  is  less  susceptible 
to  the  disease  than  the  white,  but  when  the  mortality  of  both  races  is 
examined,  the  reverse  seems  to  be  true ;  in  other  words  the  general  mortality 
and  case  fatality  rates  are  higher  for  the  negroes  than  for  the  whites.  The 
reason  for  this  apparent  anomaly  cannot  be  positively  stated,  but  it  is 
probable  that  all  cases  of  the  disease  among  the  negroes  were  not  detected, 
while  deaths  had  to  be  reported  before  the  bodies  could  be  buried.  A 
plausible  explanation  may  possibly  thus  be  found  for  the  apparently  low 
incident  rate  and  high  mortality  rate  among  negroes.  (See  table  VII  in  the 
Appendix.) 

Incidence  and  Mortality — 

From  June  1st  to  November  1st,  during  which  time  the  epidemic 
lasted,  there  were  reported  in  Greater  New  York  eight  thousand  nine 
hundred  twenty-eight  (8,928)  cases  of  poliomyelitis,  with  two  thousand 
four  hundred  and  seven  (2,407)  deaths,  giving  a  case  mortality  rate  of 
26.96  per  cent,  for  the  period  mentioned.  These  figures,  taken  from  the 
official  records  of  the  Health  Department,  show  a  greater  case  incidence 
and  mortality  from  the  disease  than  has  heretofore  been  recorded  in  any 
previous  epidemic  of  poliomyelitis.     The  complete  figures  are  given  below: 


no 

Poliomyelitis, 

June  1st  to  Nov.  1st,  1916. 

Reported  Cases  and  Deaths — Rate  per  1,000  Estimated  Population. 


Borough  Population  Cases  Deaths 

Manhattan 2,634,223  2,483  706  .94 

The  Bronx  575,877  668  167  1.16 

Brooklyn  1,928,432  4,312  1,147  2.24 

Queens  366,426  1,179  330  Z.22 

Richmond   97,d&Z  286  57  2.92 

UlY   5,602,841  8,928  2,407  1.59 


Case  Rate     Death  Rate      Case 
Per  1,000        Per  1,000      Fatal- 
Population     Population        ity 


.27 

28.43 

,29 

25.00 

.59 

26.60 

,90 

27.99 

.58 

19.93 

43 

26.96 

Urban  and  Rural  Incidence — 

The  belief  expressed  in  the  past,  especially  by  Swedish  authorities, 

that  the  incidence  of  epidemic  poliomyelitis  is  greater  in  rural  than  in  urban 

communities,  seems  to  have  proved  true  in  the  recent  epidemic  in  New 

York.     Within  the  limits  of  the  City  there  exist  extreme  examples  of  urban 

and  rural  conditions.     Thus,  the  highest  incidence  in  proportion  to  the 

population  has  been  in  those  sections  of  the  City  which  are  the  least  densely 

populated.     For   instance,   the   Boroughs   of   Queens   and   Richmond  show 

case  rates  of  3.22  and  2.92  respectively,  as  compared  to  the  Borough  of 

Brooklyn  with  a  case  rate  of  2.24,  the  Borough  of  The  Bronx,  with  a  case 

rate  of  1.16,  and  the  Borough  of  Manhattan  with  a  case  rate  of  .94  per  1000 

estimated  population.      The  total  case  rate  for  the  City  of  Greater  New 

York  was  1.59. 

Density   of  Population — City   of  Nezv   York. 

Census    of    1910. 

Number  of  Persons 
Borough  Per  Acre 

Manhattan , 176 

The  Bronx  16 

Brooklyn   42 

Queens  3.5 

Richmond 2.3 

Contacts — 

A  considerable  amount  of  work  has  been  done  by  the  Department  in  an 
effort  to  trace  possible  contacts  with  other  cases  of  the  disease,  as  an 
explanation  of  the  source  of  infection.  Notwithstanding  the  obvious  diffi- 
culty attending  the  conduct  of  such  an  investigation,  e.  g.,  in  eliciting  his- 
tories, etc.,  quite  a  large  number  of  cases  have  been  found  which  unques- 
tionably had  been  in  close  association  with  previous  cases,  either  of  readily 
recognizable  cases  of  poliomyelitis  or  ill-defined  but  suspected  cases  of  the 
disease.  In  all  such  investigations,  of  course,  the  possible  existence  of 
non-paralytic  or  abortive  cases  and  healthy  carriers  as  conveyors  of  infec- 
tion must  be  borne  in  mind.  In  this  research,  the  positive  far  exceeded 
the  negative  findings  in  importance  from  an  epidemiological  point  of  view. 


Ill 

As  an  illustration  of  the  probable  contact  relation  between  cases,  repro- 
ductions of  a  series  of  pin  or  spot  maps  from  photographs  are  herewith 
attached,  giving  the  location  of  each  case  during  the  epidemic.  Throughout 
the  epidemic  these  pin  maps  were  prepared  for  each  borough  of  the  city 
from  day  to  day  as  the  cases  were  reported.  Such  maps  show,  in  a  striking 
way,  the  general  extent  of  the  epidemic,  and  the  distribution  of  the  cases 
in  the  various  boroughs  of  the  cit\-.  The  special  serial  pin  maps  (16)  of 
the  Borough  of  Brooklyn  by  weeks  of  onset  of  the  disease,  from  May  to 
September  16,  1916.  5ho^y  the  development  of  the  epidemic  in  this  Borough, 
and  are  particularly  striking.  The  grouping  of  cases  is  at  least  suggestive 
of  probable  contact  infections.      (See  ]\Iap5  in  the  Appendix.) 

The  special  investigation  of  this  subject  was  the  main  object  of  the 
staff  supported  by  the  Rockefeller  Foundation.     The  report  of  the  Director, 
Dr.  A.  H.  Doty,  as  approved  by  the  Committee  in  charge  has  been  sum 
marized   as   follows : 

Scope  of  the  Co-oper,\ti\*e  Work. 

"  The  starting  point  of  the  co-operative  work  of  the  Committee, 
which  was  carried  out  by  a  field  force  of  physicians  and  nurses  under 
the  supen."ision  of  the  ^Medical  Director,  was  the  belief  that  mild 
cases  of  poliomyelitis  were  escaping  early  detection  and  hence  con- 
stituted a  source  of  infection  not  being  brought  under  prompt  sani- 
tan,-  control.  ^ 

"  While  this  was  the  original  and  remained  the  main  object  of 
the  Avork  of  the  organization  created  by  the  ^Mayor's  Committee  and 
supported  by  the  Rockefeller  Foundation,  the  investigations  of  the 
field  force  extended  beyond  this  purpose.  The  next  or  subsidiary 
undertaking  was  the  collection  of  data  bearing  on  such  questions  as 
the  source  of  infection  in  poliomyelitis,  the  incubation  period  of  the 
disease,  the  discover)'  and  report  to  the  Department  of  Health  of 
infractions  of  the  sanitan.'  regulations  and  other  germane  matters 
coming  under  the  personal  observation  of  the  visiting  doctors  and 
nurses. 

'•■  The  plan  of  work  was  to  follow  the  cases  reported  to  the  :\Iedical 
Director  dailv  by  the  Department  of  Health  to  their  homes  and  then, 
after  obtaining  a  list  of  relatives,  friends  and  acquaintances,  to  go 
to  their  abodes  in  order  to  ascertain  whether  cases  definitely  polio- 
mveHtis  or  of  cases  of  undiagnosed  illness  occurred  among  them. 
When  anv  were  discovered  they  were  reported  to  the  Department  of 
Health  whose  inspectorial  staff  took  charge  and  became  responsible 
for  subsequent  action  in  connection  with  the  cases.  Twenty  cases 
of  poliomvelitis  w-hich  had  not  previously  been  reported  to  the 
Department  of  Health  were  detected  in  their  early  beginnings  in  this 
wav.  and  reported. 

"■  The  Department  of  Health  altorded  the  most  cordial  and  help- 
ful assistance  to  the  field  force  of  the  Committee.  It _ provided  also 
adequate  quarters  to  the  Medical  Director  and  his  staff  in  the  buildmg 
of  the  Deoartment  in  Brooklyn  and  suppHed  a  daily  hst  of  reported 
cases  on  the  basis  of  which  the  visits  were  made.    I  desire,  therefore, 


112 

to  express  for  myself,  my  working  stafif,  and  the  Committee,  sincere 
appreciation  of  the  efficient  and  courteous  assistance  rendered  by  the 
officials  of  the  Department. 

"  As  will  be  patent  from  the  statement  regarding  the  main 
objects  of  the  work  of  the  special  committee,  the  visits  of  inquiry 
of  nurses  and  physicians  often  carried  them  far  away  from  the  case 
from  which  the  investigation  started.  The  following  of  the  clues 
thus  indicated,  provided  the  chief  material  on  which  the  essential 
portion  of  this  report — namely,  the  evidence  for  personal  contact  as 
the  source  of  infection — is  based.  In  every  instance  decision  as  to 
whether  a  given  case  of  illness  believed  to  be  poliomyelitis  was 
actually  such  a  case  was  determined  by  a  representative  of  the 
Department  of  Health,  whose  records  have  been  taken  as  final.  In 
certain  instances,  however,  the  evidence  is  less  perfect.  When,  for 
example,  the  clues  led  to  previous  cases  of  illness  which  occurred 
some  time  prior  to  the  onset  or  report  of  the  recent  cases  from  which 
the  investigation  started,  it  became  necessary  to  accept  descriptions 
which  could  not  always  be  verified  by  an  examination  of  the  children 
who  had  been  ill.  But  even  here  the  existence  of  paralysis  or  occur- 
rence of  death,  preceded  by  paralysis  of  the  respiratory  function, 
made  the  diagnosis  of  poliomyelitis  a  reasonable  one.  It  was  only 
in  dealing  with  presumptive  instances  of  the  mild  or  ambulatory 
form  of  poliomyelitis  to  which  the  name  "  abortive  "  is  applied,  that 
real  doubt  entered  into  the  decision.  But  as  care  is  taken  in  this 
report  to  indicate  all  such  doubtful  examples,  no  serious  error  has, 
it  is  believed,  been  introduced  into  the  observations. 

"  As  will  be  noted,  the  actual  work  in  the  field  began  on  July 
17th  and  terminated  on  September  20th,  covering,  therefore,  a  space 
of  about  two  months. 

Analysis  of  the  Data. 

"Number  of  cases  visited.  This  report  is  based  upon  a  study 
of  5,496*  cases  declared  by  the  Department  of  Health  to  be  cases  of 
poliomyelitis  visited  by  members  of  the  field  force  of  the  special 
committee.  The  records  were  carefully  verified  by  hospital  reports 
so  that  it  is  safe  to  say  that  errors  in  diagnosis  have  been  excluded 
as  far  as  they  possibly  could  be.  While  it  would  be  going  too  far  to 
say  that  no  error  could  have  crept  in,  it  is  fair  to  state  that  in  the 
opinion  of  the  Medical  Director  they  may  be  regarded  as  at  most 
so  few  as  to  be  negligible. 

"  A  discrepancy  exists  among  some  of  the  figures  given  in  the 
table  and  which  arises  from  the  fact  that  the  totals  do  not  always 
agree  with  the  full  number  of  cases — 5,496 — investigated.  The 
divergencies  represent  the  number  in  which  information  was  either 
not  available  at  all,  or  not  regarded  as  sufficiently  authentic  to  be 
considered  and  entered. 

"  Obviously  statements  obtained  from  members  of  a  family 
regarding  previous  illness,  contacts  with  other  persons,  and  on  many 
other  topics  which  come  up  in  an  epidemiological  investigation,  must 
always  be  confirmed  in  order  to  be  of  value.     In  the  course  of  our 


*  The  total  number  of  cases  occurring  in  the  greater  city  during  1916  is  given  by 
the  Department  of  Health  as  9,023. 


113 

field  studies  we  had  to  deal  with  much  loose  or  worthless  testimonv 
of  this  sort.  As  far  as  possible,  we  avoided  falling  into  errors  from 
this  source. 

Sources  of  Ixfectiox. 

"  This  subject  was  kept  in  the  foreground  of  the  investigation 
because  upon  it  depends  efficiency  of  sanitary  measures  of  control 
of  the  epidemic. 

'*  At  first  thought,  it  might  seem  that  the  very  large  amount  of 
material  available  during  the  recent  epidemic  would  facilitate  the 
task  of  determining  the  source  of  infection  in  poliomyelitis.  Yet.  it 
was  just  the  great  number  of  cases  scattered  throughout  a  large  and 
densely  populated  city  which  tended  to  make  this  inquin,'  far  more 
difficult  than  it  would  have  been  in  a  small  and  sparsely  settled  com- 
munit}'  containing  few  and  often  widely  separated  cases. 

"'  A  word  about  the  procedures  which  were  regularly  followed : 
In  obtaining  evidence  regarding  the  presumed  source  of  infection  in 
given  instances,  not  only  was  proof  required  that  direct  associatioti 
was  present  but  also  means  were  taken  to  develop  and  exclude  other 
possible  sources  of  infection. 

"  In  the  first  instance  the  original  cases  investigated  and  the 
ones  declared  to  be  the  source  of  infection  were  declared  to  be  true 
cases  of  poliomyelitis  officially  reported  to  us  by  the  Department  of 
Health.  This  original  diagnosis  was,  moreover,  verified  later  from 
the  hospital  records.  In  the  next  place,  satisfactory-  evidence  of 
association  or  contact  between  the  affected  persons  and  under  con- 
ditions likely  to  transmit  infection  was  demanded,  as  was  the  estab- 
lishment of  a  proper  or  probable  period  of  incubation. 

'■  The  following  of  this  rule  excludes  a  considerable  group  of 
cases  in  which  the  evidence  of  the  source  of  infection  is  good  enough 
to  be  probable,  but  not  complete  enough  to  be  acceptable.  We  sought 
not  so  much  quantity  as  quality  of  evidence  bearing  on  this  all-impor- 
tant question  of  the  source  of  infection. 

"Five  hundred  and  ninety-nine  of  the  cases  of  poliomyelitis 
investigated  by  us.  or  something  over  10  per  cent,  of  the  total  number 
we  visited,  furnished  evidence  in  accord  with  the  rule  laid  down, 
which  we  regard  as  reliable  and  thus  as  conclusive  as  the  source  of 
infection  being  of  the  nature  of  personal  contact.  In  passing,  it  will 
be  proper  at  this  point  to  state  that  our  investigation  of  the  epidemic 
at  Xew  Rochelle,  embracing  125  cases,  gave  personal  contact  as  the 
source  of  infection  in  about  30  per  cent,  of  the  instances. 

'■'  It  is  not  our  intention,  in  this  report,  to  discuss  the  general 
evidences  presented  for  and  against  the  notion  of  personal  contact 
as  the  source  of  infection  in  epidemic  poliomyelitis ;  our  -purpose  is 
merely  to  present  the  facts  as  found  by  us  and  then  to  draw  the 
conclusions  which  they  seem  to  warrant.  But  as  the  arguments 
sometimes  tend  to  mislead  because  they  are  not  based  on  accurate 
data,  we  will  first  give  them  and  then  make  comments  which  may 
help  to  clarify  the  subject. 

"  For  example,  it  is  frequently  stated  that  it  is  rare  for  more 
than  one  child  in  a  family  to  be  attacked,  thereby  implying  that  the 
infection  is  not  communicated  by  personal  contact.  Obviously,  before 
this  argument  can  become  valid,  the  facts  themselves  on  which  it  is 


114 

based  must  be  established  and  we  must  also  have  accurate  informa- 
tion concerning  the  number  of  children  in  the  families  of  the  affected. 

"Our  tabulation  has  been  prepared  from  this  point  of  view.  It 
may  be  said  to  show  that  in  far  the  greater  number  of  instances  in 
which  one  child  was  attacked  in  a  family,  the  family  contained  one 
or  two  children  residing  at  home;  and  that  as  the  number  of  children 
increased  per  family,  the  instances  of  single  cases  diminished. 

"  Moreover,  the  instances  of  two  children  attacked  in  a  given 
family  are  not  as  small  as  usually  intimated ;  while,  as  will  be  ob- 
served, 13  families  had  3  children,  2  families  4,  and  2  families  5 
children  affected  (Department  of  Health  does  not  confirm  5  cases 
in  a  family).  In  all  the  tabulations  given,  account  has  been  taken 
only  of  the  number  of  children  residing  at  home  or  directly  exposed 
to  infection. 

"  A  special  study  was  made  of  a  group  of  250  cases  in  families 
in  which  more  than  a  single  child  was  attacked.  No  instance  was 
encountered  in  which  the  first  child  affected  was  less  than  six  months 
old.  However,  at  one  year  of  age,  when  a  child  is  able  to  move  about 
of  its  own  volition  and  is  left  at  times  on  stoops  and  doorsteps  to 
play,  through  which  greater  exposure  occurs  and  hence  opportunity 
for  infection  increases,  our  records  show  that  fifteen  children  of  this 
age  group  were  the  first  in  the  family  to  develop  poliomyelitis.  At 
the  next  age  period,  namely  two  years,  when  the  child  is  still  more 
active  and  independent,  49  children  were  the  first  to  be  taken  ill  in 
family,  while  at  three  years  of  age  the  number  first  affected  has 
increased  to  60. 

"  Hence,  these  examples  would  seem  to  indicate  that  the  danger 
of  infection  increases  with  and  depends  largely  on  more  frequent 
contact  of  one  child  with  another.  Of  course,  in  the  case  of  very 
young  and  nursing  children  the  movements  of  the  mother  or  nurse 
may  be  decisive.  For  example,  such  a  young  child  brought  into  a 
house  in  which  a  case  of  poliomyelitis  exists  or  being  fondled  by  a 
"  carrier  "  or  ambulant  case  of  the  disease  will,  of  course,  be  directly 
subjected  to  infection  by  contact. 

"  It  will  be  of  interest,  at  this  point,  to  introduce  a  few  illus- 
trative examples  of  transmission  of  poliomyelitis,  both  within  the 
family  and  from  one  family  to  another. 

"Example  1.  Family  consisting  of  father,  mother  and  five 
children,  residing  in  a  particularly  well-appointed  dwelling  house 
within  spacious  grounds  in  Greater  New  York. 

"  On  July  3,  a  daughter  nine  years  of  age  stated  that  she  felt 
ill ;  first  visited  by  a  phvsician  on  July  9.  Paralvsis  occurred  on 
July  12. 

"  On  July  5,  a  daughter  aged  three  years  became  ill. 

"  On  July  14,  a  son  aged  five  and  a  half  years  became  ill. 

"  On  July  17,  the  remaining  child,  a  baby  nine  months  old,  was 
attacked. 

"  All  the  children  were  officially  declared  to  have  poliomyelitis 
except  the  patient  taken  ill  on  July  5,  in  which  instance  a  definite 
diagnosis  was  not  made,  although  it  is  quite  probable  that  this  was 
an  abortive  case. 

"  In  this  instance  we  may  note  that  although  the  family  at  first 
declared  that  the  children  had  not  been  in  direct  or  indirect  contact 


IIS 

with  a  case  of  poliomyelitis  and  could  not  have  become  infected  by 
exposure,  yet  a  minute  investigation  disclosed  the  fact  that  oppor- 
tunity for  such  exposure  actually  existed.  It  is  not  uncommon  to 
meet  with  misleading  statements  of  this  kind  which  can  often  be  set 
aside  but  only  after  painstaking  inquiry. 

"Example  2.  Family  consisting  of  father,  mother  and  eight 
children,  residing  in  a  dwelling  house  in  Greater  New  York  sur- 
rounded by  large  and  well-appointed  grounds. 

"  On  August  18,  a  daughter  aged  nine  years  became  ill. 

"  On  August  21,  a  son  twelve  years  became  ill. 

"  On  August  23,  a  daughter  aged  four  years  become  ill ;  died 
August  25. 

"  On  August  25,  a  daughter  aged  six  years  became  ill ;  died 
August  26. 

"  On  August  30,  a  son  aged  seven  years  became  ill. 

"  All  these  cases  were  officially  declared  to  be  poliomyelitis. 

"  Example  3.  Family  consisting  of  father,  mother  and  four 
children,  residing  in  a  tenement  house  in  Greater  New  York. 

"  On  July  28,  a  daughter  aged  five  became  ill. 

"  On  August  1,  a  daughter  aged  seven  became  ill. 

"  On  August  3,  two  baby  girls  (twins)  aged  one  year  became  ill. 

"  Three  of  these  cases  were  officially  declared  to  be  poliomyelitis ; 
the  daughters,  aged  five  and  seven,  and  one  of  the  twins.  No  diag- 
nosis was  made  in  the  case  of  the  remaining  twin,  so  that  doubt 
remains  whether  or  not  this  was  an  abortive  case  of  the  disease. 

"  Example  4.  Family  consisting  of  father,  mother  and  four 
children,  residing  in  a  private  dwelling  in  Greater  New  York. 

"  On  August  2,  a  daughter  aged  one  and  a  half  years  became 
ill ;  died  at  home. 

"  On  August  5,  a  son  aged  five  years  became  ill. 

"  On  August  7,  a  daughter  aged  nine  years  became  ill. 

"  On  August  10,  a  daughter  aged  seven  years  became  ill ;  died 
in  hospital. 

"  These  cases  were  all  officially  declared  to  be  poliomyelitis. 

"  Example  5.  Family  consisting  of  father,  mother  and  five 
children,  residing  in  a  private  dwelling  in  Greater  New  York. 

"  On  July  12,  the  mother,  thirty  years  of  age,  became  ill.  She 
did  not  seek  medical  advice  until  July  17,  five  days  afterward,  when 
her  son,  aged  three  and  a  half  years,  was  taken  ill  with  similar 
symptoms.  A  physician  was  called  and  subsequently  a  Department 
of  Health  official,  who  declared  both  cases  to  be  poliomyelitis.  They 
were  removed  to  a  hospital  for  treatment. 

"  Example  6.  Family  consisting  of  father,  mother  and  four 
children,  residing  in  Greater  New  York. 

"  On  July  24,  a  son  aged  eight  years  of  age  became  ill. 

"  On  July  27,  a  son  aged  three  years  became  ill. 

"  On  July  29,  a  daughter  aged  six  years  became  ill. 

"  These  cases  were  all  officially  declared  to  be  poliomyelitis. 

"Example  7.  This  example  shows  infection  transmitted  from 
one  family  to  another,  both  families  residing  in  tenement  houses. 
In  one  of  these,   a   family  consisting  of   father,   mother  and  three 


116 

children,  a  girl  five  years  old  was  taken  ill  on  August  18.  On  the 
following  day  she  was  examined  by  a  Department  of  Health  official 
and  declared  to  be  a  case  of  poliomyelitis ;  removed  to  a  hospital. 
August  23  a  brother,  aged  three  years,  was  taken  ill,  and  on  the  fol- 
lowing day,  August  24,  the  case  was  also  officially  declared  to  be 
poliomyelitis,  and  the  boy  was  removed  to  the  hospital. 

"  On  August  18,  a  boy  five  years  of  age,  the  son  of  a  neighbor, 
visited  the  above  family  and  was  with  the  child  five  years  of  age, 
who  was  taken  ill  that  day,  and  was  beside  the  couch  when  she 
vomited.  Four  days  afterward,  August  22,  this  boy  was  also  taken 
ill  and  was  under  the  care  of  a  private  physician  who,  on  August  27, 
notified  the  Department  of  Health  that  the  child  had  poliomyelitis. 
The  patient  died  on  the  same  day. 

"  Example  8.     Family  consisting  of   father,  mother  and  three 
children,  residing  in  a  private  dwelling  in  Greater  New  York. 
"  On  August  12,  a  son  aged  two  years  became  ill. 
"  On  August  13,  the  twin  brother  of  the  above  child  became  ill. 
"  On  August  15,  a  daughter  five  years  of  age  became  ill. 
"  These  cases  were  officially  declared  to  be  poliomyelitis. 

"  Example  9.  Father,  mother  and  two  children,  residing  in  a 
private  dwelling  in  Greater  New  York. 

"  On  August  9,  a  boy  of  this  family,  three  years  of  age,  was 
associated  closely  with  the  child  of  a  neighbor,  a  girl  two  years  old, 
who  was  visiting  at  the  boy's  house.  While  there  the  girl  was  taken 
sick  and  vomited  and  returned  home  but  was  not  attended  by  a 
physician  until  August  14.  The  case  was  officially  declared  polio- 
myelitis and  was  removed  to  a  hospital  on  August  22. 

"  The  boy,  exposed  on  August  9,  was  taken  ill  three  days  after- 
ward, August  12,  and  died  on  August  14.  This  case  was  also 
officially  declared  poliomyelitis. 

"  Example  10.  Father,  mother  and  four  children,  residing  in 
private  dwelling  in  Greater  New  York. 

"  On  August  10,  a  son,  aged  two  years,  was  taken  ill ;  no  physi- 
cian in  attendance.  In  a  few  days  the  child  apparently  recovered, 
but  again  became  ill  on  August  24  with  convulsions  and  died  on 
August  26. 

"  On  August  19,  a  son  aged  six  years  was  taken  ill.  He  was 
treated  by  a  private  physician,  who,  the  mother  states,  did  not  diag- 
nose the  case. 

"  On  August  22,  a  daughter  aged  four  years  became  ill. 

"  On  August  23,  a  son  three  years  of  age  became  ill. 

"  The  child  who  died  on  August  26  was  declared  to  be  a  case 
of  poliomyelitis.  No  definite  diagnosis  was  made  in  the  remaining 
cases,  although  there  is  reason  to  believe  that  they  were  instances 
of  the  abortive  type  of  the  disease. 

"Example  11.  Family  consisting  of  father,  mother  and  three 
children. 

"  During  the  latter  part  of  June  the  mother,  forty  years  of  age, 
was  taken  ill  with  headache,  fever  and  vomiting.  This  continued 
for  a  number  of  days.    The  case  was  not  under  medical  treatment. 

"About  July  15  a  son  aged  three  and  a  half  years  was  taken 
ill.  A  physician  was  called  and  treated  the  case  as  a  bilious  attack. 
The  child  recovered. 


117 

"_A  few  days  later  a  son  aged  two  and  a  half  years  wa?  seized 
in  a  similar  way  and  was  treated  for  indigestion.  He  also  recovered 
in  a  few  days. 

"  On  August  19  another  son,  aged  six  years,  became  ill  and  was 
also  treated  for  indigestion.  Twelve  days  afterward  this  case  was 
diagnosed  as  poliomyelitis  by  the  Department  of  Health  official.  It 
is,  of  course,  not  established,  but  it  nevertheless  seems  very  probable 
that  this  example  represents  a  series  of  successive  cases  of  doHo- 
myelitis. 

"Example  12.  Family  consisting  of  father,  mother  and  three 
children. 

"  On  ]\Iay  20  the  mother  came  from  Staten  Island  to  Brooklyn 
to  find  a  living  apartment  and  visited  a  number  of  places  for  this 
purpose.  She  visited  one  apartment  in  which  a  child  was  ill,  although 
there  was  no  intimation  that  the  patient  had  an  infectious  disease. 
A  few  days  later  the  mother  was  taken  ill  with  symptoms  suggestive 
of  poliomyelitis,  but  had  no  medical  attendance. 

"  On  June  15,  a  daughter  aged  nineteen  months  was  taken  ill 
and  became  paralyzed  in  both  legs. 

"  On  June  19,  a  daughter  aged  six  was  taken  ill. 

"  On  June  25,  a  son  four  years  of  age  was  also  taken  ill. 

"  Two  of  these  children  were  declared  to  be  cases  of  poliomye- 
litis by  the  Department  of  Health  and  removed  to  the  hospital  on 
July  5th.  A  subsequent  examination  of  the  mother  showed  weak- 
ness of  certain  muscles  of  the  arm. 

"  The  examples  cited  indicate,  so  f?r  as  that  subject  will  be  con- 
sidered now,  that  the  onset  of  the  second  case  in  a  family  was  usually 
three  days  or  longer  after  the  first  person  fell  ill.  Probably,  there- 
fore, the  incubation  period  is  never  or  at  least  rarely  shorter  than 
that.  Since  of  two  persons  exposed  at  the  same  time,  one  may  fall 
ill  a  day  or  two  earlier  than  the  other,  instances  of  apparently  very 
'brief  incubation  period  may  be  merely  examples  of  delayed  onset 
from  a  previous  exposure. 

Period  at  Which  Isolation  Took  Place. 

"  In  endeavoring  to  limit  the  spread  of  an  infectious  and  com- 
municable disease  through  measures  of  isolation,  the  time  period 
becomes  an  important  factor.  Were  every  case  subject  to  prompt 
isolation,  much  more  would  be  accomplished.  Very  often  delays 
occur  of  which,  in  respect  to  poliomyelitis,  some  are  unavoidable. 
In  regard  to  the  5,496  cases  investigated  by  us,  the  average  interval 
between  the  time  of  onset  of  the  first  symptoms  and  the  date  upon 
which  the  cases  came  under  the  observation  of  the  Department  of 
Health  was  five  and  one-half  days.  The  interval  was  longest  at  the 
outset  of  the  epidemic  and  was  shortened  as  the  profession  of  the 
City  became  more  aroused  and  more  experienced  in  detecting  or 
suspecting  the  rather  indefinite  symptoms  with  which  many  cases 
begin.  Sometimes,  also,  and  indeed  among  the  poorer  people  com- 
monly, no  physician  is  called  in  for  several  days.  Since  not  a  few 
cases  of  the  abortive  disease  never  develop  severe  illness  and  recover 
completely  in  a  few  days,  they  may  never  come  under  medical  atten- 
tion at  all  and  of  course  are  never  isolated. 

"  Another  source  and  cause  of  delay  in  isolation  is  found  in  mis- 
taken diagnosis.  As  just  indicated,  the  symptoms  at  the  beginning  may 


118 

be  quite  misleading.  Of  our  series  of  cases,  941  were  first  erroneously 
diagnosed  by  the  attending  physician.  Subsequently  he  would  some- 
times correct  the  diagnosis  himself ;  at  others  the  Department  diag- 
nostician made  the  correction.  In  the  interval  there  was,  of  course, 
no  isolation  whatever  practiced.  About  half  o'f  the  cases  erroneously 
diagnosed  were  considered  as  forms  of  gastro-intestinal  disturbance, 
about  10  per  cent,  cases  of  pneumonia,  and  about  3  per  cent,  cases 
of  meningitis.  In  considering  this  aspect  of  the  subject,  the  attend- 
ing physician  cannot  be  charged  with  carelessness,  since  until  recently 
he  had  almost  no  opportunity  to  become  acquainted  with  poliomyelitis 
in  its  milder  and  atypical  forms  especially,  which  only  lately  have 
been  more  and  more  emphasized. 

Non-Paralytic    (or  Abortive)    Poliomyelitis. 

"  A  special  inquiry  was  directed  to  this  class  of  cases  because 
of  their  important  bearing  on  the  spread  of  the  disease.  Many 
of  the  cases  do  not  come  under  medical  supervision  at  all  and  hence 
escape  all  control,  and  they  act  as  active  agents  for  the  further  dis- 
tribution of  the  infection.  Two  groups  of  cases — one  of  509  and 
the  other  of  469 — came  under  consideration. 

"  The  former  group  relates  to  persons  taken  ill  just  preceding 
or  immediately  following  officially  reported  cases  of  poliomyelitis 
with  which  they  had  been  in  contact.  Some  were,  others  were  not, 
attended  by  physicians ;  in  some  instances  slight  paralysis  occurred. 
The  history  of  this  group  of  cases  was  obtained  by  the  visiting  nurses, 
although  the  actual  illness  could  not  be  verified ;  and  the  history  of 
the  instances  in  which  the  illness  followed  officially  declared  cases 
was  not  obtained  until  the  second  visit  of  the  nurse,  made  a  month 
or  more  afterwards. 

"  It  can  be  surmised  only  that  part  of  these  cases  were  instances 
of  poliomyelitis ;  but  the  symptoms  described  were  often  very  sus- 
picious— which,  taken  together  with  the  fact  that  exposures  had 
actually  occurred,  insures  that  a  percentage  were  true  mild  or  abor- 
tive cases. 

"  This  conclusion  is  in  a  measure  confirmed  by  a  consideration 
of  the  second  group  of  persons,  consisting  of  469  cases,  ill  at  the 
time  the  district  nurse  visited  the  premises.  Many  of  these  persons 
were  only  little  ill,  and  had  no  medical  attendance  whatever.  Each 
case  was  none  the  less  reported  to  the  Department  of  Health,  whose 
official  records  show  that  about  25  per  cent,  proved  to  be  cases  of 
poliomyelitis. 

"  We  encountered  various  instances  in  which  evidence  pointed 
to  mild,  abortive,  or  unrecognized  cases  as  being  the  immediate  fore- 
runner of  marked  and  obvious  cases  of  poliomyelitis.  An  example 
will  be  given. 

"  '  Five  families  residing  in  adjacent  houses  in  Greater  New 

York   were   closely   affiliated   in   a   social   way.      Three    of   the 

families  each  had  one  child ;  one  family  had  three  children,  and 

the  remaining  family  two  children.     The  children  were  taken 

daily  by  their  mothers   to   a  nearby  park,   where  they  played 

together  while  their  mothers  sewed. 

" '  About  June  30  one  o'f  these  children  became  ill,  with 

vomiting,  diarrhoea,  fever,  and  headache.     The  family  physician 


119 

was  called  and  pronounced  the  case  not  serious — only  a  gastro- 
intestinal attack — and  recommended  that  the  child  be  kept  in 
bed  for  a  day  or  so  and  then  allowed  to  get  up.  At  the  end  of 
this  period  the  mother  found  that  the  child  moved  with  difficulty, 
as  its  legs  were  stifif.  The  attending  physician  was  again  called 
and  stated  that  this  condition  amounted  to  nothing  and  would 
disappear  within  a  few  days,  which  it  did. 

"  '  On  July  5  a  child  belonging  to  another  family  of  this 
group  also  became  ill.  In  this  instance  the  symptoms  of  polio- 
myelitis were  well  marked  and  the  family  physician  notified  the 
Department  of  Health.  The  child  was  visited  by  a  health 
official,  declared  to  be  a  case  of  poliomyelitis,  and  removed  to 
a  hospital. 

"  '  Evidently  the  circumstances  relating  to  the  illness  of  the 
child  first  affected  were  not  officially  reported.  When  the  second 
case  was  announced,  the  mothers  whose  children  were  not  ill 
promptly  left  New  York  with  their  families  and  went  to  a 
boarding  house  in  an  adjoining  State  to  escape  infection.  Before 
July  10,  all  the  children  of  this  group  were  attacked  with  polio- 
myelitis. One  died,  and  evidences  of  paralysis  appeared  among 
the  others.  Although  the  report  of  this  occurrence  obtained 
from  the  families  of  this  group  bore  every  evidence  of  veracity, 
it  was  deemed  important  that  it  should  be  properly  verified. 
Therefore,  the  health  officer  of  the  township  where  the  boarding 
house  was  situated  was  communicated  with.  He  confirmed  the 
statement  already  made,  declaring  that  in  his  opinion  all  of  the 
children  had  had  poliomyelitis.' 

"  The  example  clearly  shows  that  the  first  child  affected  was  an 
abortive  or  unrecognized  case  of  poliomyelitis,  and  was  the  source  of 
infection  to  the  other. 

"  Finally  and  in  this  connection  a  word  may  be  added  on  the 
subject  of  the  healthy  carrier  of  the  infectious  agent  of  poliomyelitis. 
Our  study,  because  of  its  nature,  could  not  take  cognizance  of  this 
factor,  except  to  the  extent  of  excluding  it  when  possible  by  obtaining 
evidence  or  indication,  in  cases  of  suspect  carrier  infection,  that  con- 
tact with  an  actual  case  of  the  disease  had  taken  place.  We  have  no 
figures  to  present  on  this  very  difficult  topic ;  but  we  believe  that  the 
more  incisively  the  matter  is  investigated,  the  greater  will  the  actual 
number  of  contacts  with  actual  cases  be  found  to  be. 

Incubation  Period. 

"  To  establish  a  determined  period  of  incubation  during  an  ex- 
tended outbreak  of  such  an  infectious  disease  as  the  one  we  are  con- 
sidering in  a  thickly  populated  city,  in  which  infection  is  widespread 
and  cases  are  continually  occurring,  involves  difficulties  and  uncer- 
tainties which  seriously  affect  the  validity  of  the  result  achieved. 

"  It  is,  of  course,  far  easier  to  establish  an  apparent  period  of 
incubation.  In  sparsely  settled  communities  the  former  is  often 
capable  of  accurate  estimation ;  in  thickly  populated  communities,  the 
latter  has  always  to  be  dealt  with.  Thus  the  period  of  incubation  in 
connection  with  a  group  of  infected  persons  in  which  more  or  less 
continuous  association  is  going  on  cannot  be  accurately  fixed.     On 


120 

tlie  other  hand,  when  one  child  in  a  family  falls  ill  of  poliomyelitis 
and  a  second  child  develops  the  disease  six  days  later,  the  incubation 
period  is  usually  put  at  six  days.  And  yet,  as  we  cannot  ascertain 
the  precise  moment  of  infection,  it  may  actually  be  less  than  that 
period. 

"  The  other  extreme  is  that  in  which  a  second  or  subsequent  case 
of  poliomyelitis  appears  within  a  day  or  two  of  the  first,  suggesting 
coincident  infection,  which  is  what  it  probably  is.  And  yet,  even  this 
involves  an  assumption  regarding  the  incubation  period  which  may 
be  incorrect.  Instances  of  so-called  determined  incubation  periods, 
as  brief  as  two  days,  have  been  given  by  certain  authors ;  they  arouse, 
however,  grave  suspicion  as  to  their  validity. 

"  In  our  tabulation  we  have  tried  to  distinguish  between  the 
apparent  and  determined  incubation  perio'ds ;  584  cases  fall  into  the 
first  and  15  into  the  second  category.  It  is  interesting  to  observe 
that  one-third  of  the  latter  fall  on  the  third  day  and  two-thirds  within 
eight  days.  But  a  greater  number  of  instances  of  "  determined  " 
incubation  periods  must  be  assembled  before  we  shall  know  whether 
the  figures  obtained  in  our  investigation  represent  the  true  periods. 

"  No  further  comments  on  the  apparent  period  are  perhaps  called 
for.  The  large  number  of  instances  following  in  the  first  three  days 
is  noteworthy,  but  cannot  be  regarded  as  in  the  nature  of  conclusive 
testimony  in  favor  of  a  very  short  incubation  period.  In  other 
words,  the  question  is  left  by  our  study  approximately  where  it  was, 
the  critical  time  falling  within  the  first  seven  or  eight  days  of 
exposure. 

"  It  has  occurred  that  a  period  of  two  or  three  weeks  has  elapsed, 
or  seems  to  have  elapsed,  between  the  onset  of  a  first  and  second 
case  in  a  family.  The  question  arising  is  whether  the  long  period 
is  to  be  regarded  strictly  as  incubation  time  or  whether  the  associa- 
tion may  not  have  existed  for  several  days  before  actual  communica- 
tion of  the  infectious  agent  took  place.  Of  the  two  alternative  possi- 
bilities, the  second  seems  more  likely. 

Summary. 

"  The  investigation  carried  out  by  the  field  force  of  your  com- 
mittee, under  my  direction,  has  supplied  information  of  two  kinds: 

"  First,  information  of  practical  daily  import  was  obtained  by 
the  physicians  and  nurses  who  visited  premises  in  which  cases  of 
poliomyelitis  occurred  and  the  relatives  and  friends  of  the  affected 
families,  which  was  turned  over  immediately  to  the  Department  of 
Health  for  its  use  and  guidance. 

"  Second,  the  data  thus  collected  and  recorded  were  subsequently 
collated  and  analyzed  in  the  hope  that  light  might  be  thrown  on  the 
important  questions  of  source  of  infection,  period  of  incubation, 
types  of  disease,  significance  of  food,  of  diseases  among  domestic 
animals,  insects,  and  some  other  subsidiary  topics. 

"  This  second  line  of  inquiry  yielded  information  which  led  us 
to  regard  the  disease  as  one  (a)  communicated  by  personal  contact, 
(&)  in  which  the  slight  and  abortive  cases  are  the,  most  frequent 
sources  of  the  contagion,  and  (c)  in  which  the  incubation  period 
varies  between  three  and  ten  days.  We  were  not  able  to  make  a  study 
of  the  question  of  the  healthy  carrier,  but  we  think  it  probable  that 


121 

he  plays  a  less  conspicuous  part  in  disseminating  the  infection  than 
does  the  mild  and  often  unrecognized  case  of  the  disease. 

"  We  gave  especial  attention  to  the  working  out  of  the  incuba- 
tion period  on  the  basis  of  the  data  collected.  Recognizing  the  diffi- 
culties and  fallacies  of  the  undertaking  in  a  large,  miscellaneous  popu- 
lation, such  as  exists  in  Greater  New  York,  we  cannot  assert  that 
our  conclusion  is  absolute.  We  think  it  probable,  however,  that  taken 
together  with  the  conclusions  of  previous  investigators,  it  is  virtually 
correct. 

''  We  could,  finally,  find  no  substantial  evidence  to  support  the 
notion  of  food,  lower  animal  or  insect  carriage  of  the  infection, 
although  in  regard  to  those  subjects  our  investigations  were  inci- 
dental rather  than  essential." 


Multiple  Cases — 

In  order  to  determine  the  frequency  with  which  more  than  one  case 
occurred  in  a  household,  a  special  investigation  was  made  of  multiple  cases 
in  families.  Out  of  the  total  number  of  cases  for  the  year  1916,  8,635 
families  were  involved. 

Multiple  Cases  of  Poliomyelitis  in  Families. 


Number 
of  Cases 
in  Family 

Manhattan 

Bronx 

B 

rooklyn 

Qi 

ueens 

Richmond 

City 

Two    .... 
Three   . . . 
Four   

Totals    . 

65 
5 
1 

71 

13 
1 
0 

14 

159 

20 

3 

182 

61 
1 
1 

63 

15 
1 
1 

17 

313 

28 

6 

347 

(1)  8287,  or  96%,  had  one  case  only.  Total  children  in  these  families 
were  24,883. 

(2)  313,  or  3.6%  had  two  cases;  28,  or  .3+%,  had  three  cases;  6  or 
.06+%  had  four  cases.  Total  children  in  these  three  groups  of  families 
were  1,516.    Total  cases  736. 

Thus,  multiple  cases  occurred  in  only  4%  of  the  families  involved — 
while  in  the  first  group,  we  find  that  over  16,500  children,  intimately  exposed 
to  the  infection,  did  not  contract  the  disease. 

The  investigation  showed  that,  in  nearly  all  instances  where  more  than 
one  case  occurred  in  a  family,  the  onsets  were  so  close  as  to  suggest  simul- 
taneous infection.  Some  cases  were  found  to  have  been  attacked  with  the 
disease  at  a  later  date,  indicating  that  they  were  probably  secondary  infec- 
tions, but  such  cases  decreased  in  number,  as  a  rule,  with  increasing  length 
of  time  from  the  first  case.  Very  exceptionally  were  secondary  cases  sepa- 
rated from  the  primary  case  by  a  longer  interval  than  two  weeks.  Similar 
results  were  obtained  in  the  study  of  multiple  cases  in  one  house;  the  ma- 
jority of  the  cases  would  appear  to  have  had  a  simultaneous  infection. 


122 

In  a  study  of  forty  cases,  where  more  than  one  case  occurred  in  a 
family, 

10  cases  occurred    1  day  from  primary  case 


2      " 

2  days    " 

3      " 

3 

a           it                 ec 

1  case 

4 

a          «                 <( 

3  cases        ' 

5 

((           «                 (( 

3      " 

6 

((              ((                      (C 

2      " 

7 

((          ((                (( 

1  case 

10 

«          ((                (( 

1      " 

13 

(<          ((                (( 

734  cases  were  reported  with  an  onset  of  five  days  or  less.  As  the 
diagnosis  of  poliomyelitis  was  held  in  abeyance  by  many  private  physicians 
until  evidence  of  impairment  of  muscular  function  was  apparent,  this  is  also 
of  value  in  showing  the  early  occurrence  of  paralysis. 

Of  1,500  of  the  total  cases  in  which  the  matter  of  previous  exposure 
was  studied  in  detail  by  a  representative  of  the  Department  of  Health,  it 
was  found  that  in  29  cases  there  had  been  direct  exposure  to  another  case  in 
the  same  family ;  in  25  instances  the  fatal  case  had  been  exposed  to  cases  out 
of  the  family ;  in  13  cases  a  member  of  the  family  had  visited  active  cases 
of  poliomyelitis  within  a  week  of  the  onset  of  the  disease  in  the  fatal  case. 

The  exact  date  of  first  exposure  as  related  to  the  date  of  first  observa- 
tion of  symptoms  in  the  fatal  cases  could  not  be  learned,  so  that  any  positive 
conclusion  as  to  whether  the  cases  above  recorded  were  secondary  in  the 
accurate  epidemiological  sense  of  the  word,  or  merely  subsequent  and 
arising  from  quite  other  and  common  source  of  infection,  cannot  be  offered. 

Regarding  the  degree  of  contagiousness  of  this  disease,  an  interesting 
comparison  may  be  made  of  the  incidence  of  diphtheria,  scarlet  fever  and 
measles,  in  a  crowded  area  of  the  city,  during  their  period  of  greater  activ- 
ity, with  the  recent  incidence  of  poliomyelitis  in  the  same  section. 

In  both  scarlet  fever  and  diphtheria  we  recognize  considerable  natural 
immunity.  Further,  in  diphtheria  an  immunity  is  commonly  conferred  by 
artificial  passive  immunization  of  exposed  persons. 

The  area  selected  for  this  comparison  was  the  congested  "  East  Side  " 
of  Manhattan,  a  district  lying  between  Broadway  and  East  Third  Street  to 
East  River,  known  as  the  Corlears  District,  having  a  total  population  of 
about  430,000  persons. 

Comparison  of  Incidence  of  Contagious  Disease,  Corlears  District. 


January 

February 

March 

April 

May 

Diphtheria  

132 

103 

58 

122 

35 

186 

123 

59 

287 

139 

Scarlet  Fever 

Measles    

41 
25 

66 

288 

June 

July 

August 

Sept. 

Oct. 

Poliomyelitis    

13 

189 

154 

20 

4 

123 

These  figures  would  seem  to  indicate  that  poliomyelitis  is  certainly  no 
more  readily  communicable  than  are  diphtheria,  scarlet  fever  and  measles, 
and  one  might  fairly  conclude  that  with  immunity  to  this  disease  as  evident 
as  that  recognized  in  the  other  so-called  "  contagious  diseases,"  in  a  fixed 
population,  its  communicability  is  decidedly  less. 

Overcroivding — 

In  order  to  determine  whether  there  was  any  relation  between  conges- 
tion and  the  spread  of  the  disease,  the  following  summary  of  data  collected 
by  the  Tenement  House  Department  is  interesting : 

In  the  Borough  of  Manhattan,  out  of  614  cases  of  poliomyehtis  occur- 
ring in  tenements,  the  largest  number  of  cases,  152  to  the  tenement,  occurred 
in  tenements  of  eighteen  apartments;  quite  a  large  number  of  cases  occurred 
in  tenements  of  three  to  ten  apartments,  but  the  smallest  number  of  cases 
occurred  in  tenements  of  thirty  to  ninety  apartments  to  the  tenement.  In 
the  Boroughs  of  The  Bronx,  Brooklyn,  Queens  and  Richmond,  a  similar 
comparative  incidence  of  cases  was  found;  the  smallest  number  of  cases 
occurred  in  the  tenements  with  the  largest  number  of  apartments  to  the 
tenement. 

In  a  study  of  1,000  cases  taken  from  the  files  in  the  Borough  of  Brook- 
lyn 

241  cases  occurred  in  private  houses, 

12  cases  occurred  in  boarding  houses, 
747  cases  occurred  in  tenement  houses. 

This  would  seem  to  show  that  the  class  of  dwelling  had  little  bearing 
on  the  case  incidence  of  the  disease. 

These  facts  are  still  further  confirmed  by  observations  made  in  particu- 
larly crowded  sections  of  the  city. 

A  small  and  quite  isolated  residential  district  in  Manhattan  lies  west  of 
Broadway,  between  Batter}^  Park  and  Liberty  Street.  The  1910  census  of 
this  area  gives  a  population  of  6,441,  with  1,463  families.  There  has  been 
little  change  since  then.  JThe  social  and  economic  conditions  are  probably 
as  bad  as  can  be  found  anywhere  in  the  city ;  the  housing  is  wretched ;  there 
is  a  great  deal  of  overcrowding,  the  residential  section,  being  greatly 
encroached  upon  by  business  buildings. 

Another  section,  the  old  "East  Side"  of  Manhattan,  south  of  East 
Third  Street  and  East  Broadway  to  the  river,  may  be  compared  with  this. 
Here  a  very  conservative  estimate  of  the  population  is  400,000.  In  all 
respects,  it  is  quite  comparable  to  the  other  district. 

In  the  Battery  Park  district,  with  its  population  of  about  6,500,  there 
were  twelve  cases  of  poliomyelitis,  or  nearly  two  per  thousand.  In  the  East 
Side,  or  Corlears  District,  there  were  342  cases,  or  0.8  per  1,000  population. 

From  these  data,  it  would  appear  that  there  was  no  real  relation  be- 
tween overcrowding  and  the  spread  of  the  disease. 


124 

Domestic  Animals  as  Carriers — 

In  order  to  determine  whether  domestic  animals  of  any  kind,  being 
affected  by  the  disease,  might  become  the  source  of  infection,  special  in- 
vestigations were  made  by  the  Department  of  Health  of  all  sick  or  paralyzed 
household  pets,  chiefly  dogs  and  cats,  discovered  in  premises  from  which 
poliomyelitis  had  been  reported.  With  the  co-operation  of  the  American 
Society  for  the  Prevention  of  Cruelty  to  Animals,  all  such  animals  were 
removed  to  the  Shelter  of  the  Society  and  there  studied. 

The  following  comparison  by  years,  for  the  months  of  June,  July, 
August,  September  and  October  of  the  number  of  dogs  and  cats  removed 
by  the  American  Society  for  the  Prevention  of  Cruelty  to  Animals  shows 
the  marked  increase  of  the  activities  of  this  Society  during  the  epidemic: 

Dogs  Cats 

Month 1914  1915  1916 1914  1915  1916 

June    3,955  3,669  4,345  20,559  22.082  32,099 

July   4,119  4,105  5,546  22,161  29,236  94,991 

August  5,258  3,873  4,977  22,459  28,845  62,204 

September  5,520  3,977  4,034  17,462  24,057  45,888 

October    4,788  3,745  3,636  11,557  20,916  34,586 

Totals 23,640         19  369         22,538 94,198       125,136       269,768 

As  the  result  of  these  investigations,  nothing  was  found  to  indicate  that 
these  animals  were  affected  by  the  disease  or  that  they  acted  in  any  way  as 
carriers  of  the  infection. 

Food  and  Milk — 

In  previous  epidemics,  the  theory  has  been  repeatedly  advanced  that 
food  or  drink  may  act  as  vehicles  of  infection  in  poliomyelitis.  The  regular 
water  supply  and  various  foods  and  drink,  particularly  ice  cream  cones  and 
soda  water,  have  been  under  suspicion  and  investigation.  Above  all,  milk 
seems  to  fit  the  requirements  as  a  medium  of  infection,  although  it  has 
never  been  proved  to  transmit  the  disease. 

It  was  decided  by  the  Department,  therefore,  to  make  a  special  study  of 
the  milk  supply,  in  cases  of  poliomyelitis  occurring  in  New  York  City,  and 
that  so  important  a  food  might  be  properly  covered,  it  was  determined  to 
apply,  in  one  borough  (The  Bronx),  the  same  searching  analysis  of  the  milk 
supply,  in  poliomyelitis,  as  is  employed  in  the  study  of  typhoid  fever.  The 
general  plan  adopted  was  as  follows: 

First,  careful  inquiry  as  to  the  milk  used  during  four  weeks  previous  to 
the  onset  of  the  infection;  second,  ascertainment  of  the  name  of  the  dealer, 
in  the  case  of  bottled,  and  the  address  of  the  store  from  which  it  was  pur- 
chased, in  the  case  of  loose  miilk ;  third,  in  each  case,  tracing  the  milk  to  the 
country ;  fourth,  close  watch  kept  by  elaborate  tabulations,  on  both  the 
dealers  and  creameries  (i.e.,  country  shipping  points)  ;  and  fifth,  when  any 
number  of  cases  were  charged  to  a  given  creamery,  prompt  investigation  at 
the  source  of  supply,  to  discover  possible  contamination. 

Data  were  carefully  kept  and  tabulated  by  onset  by  weeks  of  all  cases 


125 

supplied  by  milk  dealers.  This  tabulation  included  five  hundred  twenty-five 
(525)  cases  who  had  been  served  with  milk  by  thirty-three  (33)  dealers. 

Several  dealers  showed  a  decided  accretion  of  cases ;  in  one  instance,  of 
one  hundred  ninety-seven  (197)  cases,  and  in  another,  of  one  hundred 
seventy-one  (171)  cases.  At  first  glance,  this  would  seem  to  lead  to  a 
suspicion  of  individual  dealers,  but  on  further  consideration  it  was  apparent 
that  the  increased  accumulation  of  cases  was  consistently  in  accord  with  the 
varying  amount  of  milk  distributed  by  each  company  in  the  area  studied. 

The  milk  involved  was  largely  Grade  B  pasteurized  milk.  Some  Grade 
A  milk  from  country  pasteurizing  plants  showed  moderate  accumulation  of 
cases,  in  the  last  week  of  July  and  the  first  week  in  August.  These  plants 
were  specially  investigated,  in  the  manner  above  indicated,  as  in  typhoid 
fever.    The  result  was  altogether  negative. 

Several  smaller  studies  made  by  the  Department,  in  the  course  of 
investigation  of  food  stores  in  Brooklyn,  gave  similar  results.  One  investi- 
gation, in  the  Bay  Ridge  section,  showed  twenty-four  cases  of  poliomyelitis 
using  milk  from  twelve  different  sources.  The  other,  in  a  different  part  of 
the  borough,  showed  fifty-one  cases,  with  seventeen  different  sources  of 
milk  supply. 

Of  30,375  babies  under  two  years  of  age,  who  were  cared  for  at  the 
Baby  Health  Stations  in  New  York  City,  from  June  1st  to  October  1st,  199, 
or  0.65  per  cent.,  were  affected  with  poliomyelitis,  of  which  number  59,  or 
29  per  cent.,  died.  These  babies  were  affected  and  succumbed  to  the  disease, 
regardless  of  whether  they  were  fed  on  breast  milk  exclusively,  on  bottle 
milk  exclusively,  on  mixed  feeding,  or  given  Grade  A  Raw,  Grade  A  Pas- 
teurized or  Grade  B  milk.  Especially,  it  is  to  be  noted  that,  out  of  115 
babies  under  one  year  of  age  affected  with  poliomyelitis,  41  were  fed  on 
breast  milk  exclusively,  and  of  this  number  6  died  of  the  disease. 

Like  results  were  obtained  in  a  study*  of  199  cases  under  two  years  of 
age,  admitted  to  the  Willard  Parker  Hospital.  Of  this  number,  42  of  the 
babies  affected  were  exclusively  breast-fed,  while  97  of  the  artificially  fed 
babies  were  given  pasteurized  milk,  a  small  percentage  only  receiving  pro- 
prietary food. 

In  all  these  investigations  there  was  nothing  to  indicate  that,  in  the 
recent  epidemic,  any  food  or  drink  was  concerned  in  the  spread  of  the 
disease.  Milk  at  least  would  seem  to  have  been  eliminated  as  a  source  of 
infection  in  poliomyelitis. 

Relation  of  the  Epidemic  to  General  Mortality   Under  the  Age  of  Tzvo> 
Years — 
In  studying  the  relation  of  poliomyelitis  to  the  infant  mortality  and  to 
the  mortality  of  children  under  two  years  of  age  in  the  Greater  City,  it  will 
be  found  profitable  to  analyze  the  situatioji  from  the  following  standpoint : 

(a)   The  relation  of  the  epidemic  to  infant  mortality,  that  is,  to 
the  deaths  of  babies  under  one  year  of  age  in  the  Greater  City. 

*  By  Dr.  May  G.  Wilson,  Cornell  University,  New  York  City. 


126 

(b)  The  relation  of  the  epidemic  to  the  mortahty  of  babies  under 
two  years  of  age  in  the  Greater  City. 

(c)  The  relation  of  the  epidemic  to  the  infant  mortality  as  to 
deaths  of  babies  under  two  years  of  age  enrolled  at  under  the  super- 
vision of  the  fifty-nine  Baby  Health  Stations  in  the  Greater  City. 

(d)  The  relation  of  the  epidemic  to  the  infant  mortahty  of 
babies  under  supervision  of  district  nurses  during  July,  August  and 
the  greater  part  of  September. 

For  the  purposes  of  this  study,  comparisons  will  be  made  between  the 
first  nine  months  of  the  years  1915  and  1916,  inasmuch  as,  from  the  prac- 
tical standpoint,  it  may  be  said  that  the  epidemic  had  spent  the  greatest  part 
of  its  course  by  October  1,  1916,  and  in  view  of  the  fact  that  the  opening  of 
the  public  schools  received  official  sanction  on  September  25,  1916. 

At  the  outset  we  desire  to  submit  the  following  tabulation  of  compara- 
tive statistics  bearing  upon  an  analysis  of  this  situation,  and  to  which  we  will 
refer  from  time  to  time  in  discussing  the  many  phases  of  the  subject : 

(A)  Relation  of  the  epidemic  to  the  infant  mortality — that  is,  to  the 
deaths  of  babies  under  one  year  of  age  in  the  Greater  City: 

Despite  the  epidemic  of  poliomyelitis,  the  infant  mortality  situation  in 
the  Greater  City,  both  from  the  standpoints  of  rate  and  number  of  deaths 
under  one  year,  has  been  exceedingly  favorable.  The  infant  mortality  rate 
in  the  Greater  City  for  the  year  1915  was  98.2  per  1,000  children  born.  For 
the  first  nine  months  of  1916  we  find  the  infant  mortality  rate  98  as  against 
102  for  the  corresponding  period  of  1915.  This  took  place  in  face  of  the 
fact  that  some  961  infants,  or  about  11%  of  the  total  cases  reported,  were 
attacked  with  the  epidemic  disease,  and  that  395  of  the  infants  attacked 
succumbed.     (See  Table  XXIII  in  the  Appendix.) 

Various  observers,  or  rather  critics,  have  presented  several  reasons  for 
this  reduction  in  infant  mortality  during  the  year,  among  which  may  be 
mentioned : 

(1)  The  reduction  in  the  number  of  births; 

(2)  The  fact  that,  owing  to  the  prevalence  and  spread  of  the 
epidemic,  a  larger  number  of  infants  were  taken  out  of  the  City  this 
year  than  last  year ; 

(3)  Because  of  the  greater  exodus  from  the  City  of  infants 
under  one  year,  a  larger  number  of  these  infants  died  outside  of  the 
City  limits,  and  the  deaths  were,  therefore,  not  included  in  the  tatal 
number  of  City  infant  deaths. 

To  answer  these  seriatim : 

(1)     The  Reduction  in  the  Number  of  Births — 

It  is  true  that  there  have  been  some  three  thousand  eight  hundred  and 
forty-one  less  births  this  year  than  last  year  (see  Table  XXIII,  item  1),  and 
that  with  so  many  thousand  less  births,  it  is  to  be  expected  that  there  will  be 
numerically  fewer  deaths.  This  does  not  alter  the  fact,  however,  that  the 
infant  mortality  rate,  which  is  a  true  index  of  the  infant  mortality  situation, 
and  which  is  based  upon  the  number  of  births  during  the  year,  and  the  num- 


127 

ber  of  deaths  under  one  year,  occurring  during  that  year,  is  lower  than  for 
the  corresponding  period  of  last  year.  (See  Table  XXIII — item  5.)  But 
even  from  a  numerical  standpoint,  the  number  of  infant  deaths  for  the  first 
three-quarters  of  1916  would  have  been  lower  than  for  the  corresponding 
period  of  1915,  even  had  these  3,841  infants  been  born. 

Assuming  that  for  every  thousand  children  born,  one  hundred  would 
have  died  before  the  first  year,  we  would  have  had  some  384  more  deaths 
than  were  actually  recorded  for  1916,  namely,  10,122.  (See  Table  XXIII — 
item  2.) 

The  present  figures  show  that  for  the  first  three-quarters  of  1916  there 
were  884  less  deaths  under  one  year  of  age  than  for  the  corresponding 
period  of  last  year.  (See  Table  XXIII — item  2.)  If  we  add  to  the  number 
of  infant  deaths  for  1916  the  384  which  would  have  taken  place  had  the 
number  of  births  in  1916  been  as  large  as  1915,  we  would  still  find  that  there 
were  500  fewer  infants  dying  in  1916  than  in  1915.  It  cannot,  therefore,  be 
denied  that  despite  the  reduction  in  the  number  of  births  during  the  year, 
there  has  been  a  distinct  numerical  saving  in  infant  lives. 

(2)     Larger  Number  of  Infants  Taken  Out  of  New  York  City  in  1916? 

It  is  manifestly  impossible  to  secure  any  absolutely  reliable  data  on 
this  subject.  Impressions  vary,  some  inclining  to  the  belief  that  the  number 
of  families  and  infants  under  one  year  leaving  the  city  this  year  was  greater 
than  last  year,  and  others  taking  directly  the  opposite  view.  At  first  thought 
it  would  seem  that  the  prevalence  of  the  disease,  and  the  terror  which  it 
struck  in  the  hearts  of  the  parents,  would  cause  a  great  exodus  from  the 
city.  It  must  be  remembered,  however,  that  within  a  very  short  time  after 
the  epidemic  had  gained  a  foothold,  quarantine  regulations  berame  rather 
rigid,  and  entrance  to  other  cities  and  summer  resorts  near  New  York  was 
rendered  most  difficult,  so  that  a  large  number  of  parents  who  actually 
desired  to  take  their  infants  away  were  prevented  from  so  doing.  Other 
parents,  again,  soon  found  that  the  disease  had  found  its  way  into  the 
very  cities  and  towns  which  they  desired  to  visit,  and  they  realized  that 
their  children  were  just  as  safe  in  New  York  City,  in  fact,  safer,  because 
of  the  better  facilities,  than  outside  of  New  York. 

Many  parents  were  so  taken  up  with  the  fear  of  the  disease,  that  they 
remained  in  the  city.  As  they  put  it,  if  the  child  should  be  attacked  far 
away  from  home,  they  might  have  great  difficulty  in  returning  to  New  York, 
and  in  securing  for  it  the  proper  medical  nursing  or  hospital  care. 

It  seemed  probable  that  at  the  beginning  of  the  epidemic  not  a  few 
families,  particularly  among  the  Italian  population  of  the  Borough  of 
Brooklyn,  and  the  Jewish  tenement  dwellers  of  the  lower  East  Side  of 
Manhattan,  became  panic-stricken,  packed  up  bag  and  baggage  and  left 
the  City.     This,  however,  was  the  exception. 

It  must  be  remembered  that  many  of  the  better  situated  element  of  the 
population  who  leave  the  city  during  the  summer  months,  year  in  and  year 


128 

out,  remained  in  the  city  this  summer,  either  because  of  the  strict  quarantine 
regulations,  both  here  and  in  other  cities,  or  because  of  their  desire  to 
remain  in  a  large  city,  with  all  its  conveniences  of  transportation  and 
treatment  in  the  event  of  illness.  This  number,  in  our  opinion,  more  than 
counterbalances  the  number  leaving  the  city  at  the  beginning  of  the  epidemic. 
In  order,  if  possible,  to  determine  with  reasonable  accuracy  whether 
the  removal  of  children  from  the  city  during  the  summer  materially  affected 
the  infant  mortality  of  the  city,  an  inquiry  was  sent  to  passenger  agents  of 
all  the  railroads  having  a  terminal  in  New  York.  Replies  were  received 
from  all  of  them,  and  while  many  of  the  roads  were  unable  to  supply  us 
with  the  exact  figures,  the  consensus  of  opinion  was  that  there  had  been 
a  material  decrease  in  the  summer  trafific,  particularly  as  far  as  children 
were  concerned,  as  may  be  seen  from  the  following  quotations  from  the 
replies  received: 

"  We  notice  a  decided  falling  off  in  the  ticket  sales  for  both 
adults  and  children." 

"  We  know,  however,  from  personal  observation,  that  during  the 
first  outbreak  of  infantile  paralysis,  before  the  quarantine  was  estab- 
lished, that  a  large  number  of  children  did  leave  the  City,  but  after 
the  quarantine  was  established,  comparatively  few  did  so." 

"  Our  "records  show  that  in  July,  1915,  we  sold  6,622  tickets  for 
the  use  of  children  under  twelve  years  of  age,  whereas  in  July,  1916, 
we  sold  4,106.  In  August,  1915  we  sold  4,622  for  children  under 
twelve  years  of  age,  and  in  August,  1916,  we  sold  637  such  tickets." 

"  Approximately  300,000  adults  and  7,000  children  left  the  City 
during  July  of  this  year.  For  the  same  month  last  year  270,000 
adults  and  7,000  children.  During  the  month  of  August  this  year 
about  250,000  aduhs  left  the  City  and  2,000  children.  During  the 
same  month  last  year  245,000  adults  and  6,000  children." 

"  In  the  sale  of  half  tickets  there  was  a  decrease  of  4,616  tickets 
in  July  as  compared  with  that  month  last  year,  and  a  decrease  of 
6,579  in  August  as  compared  with  the  same  month  last  year." 

"  It  would  be  exceedingly  difficult  to  obtain  the  exact  statistics 
from  our  records,  but  an  examination  of  the  reports  of  our  principal 
New  York  offices  for  the  period  mentioned  indicate  a  decrease  of 
approximately  35  per  cent,  in  the  number  of  tickets  sold  during  the 
montlis  of  July  and  August.  1916.  as  compared  with  1915." 

^Concerning  the  relative  number  of  children  leaving  the  City, 
our  gatemen  estimate  that  there  was  a  slight  increase  in  Julv  and 
August.  1916,  compared  with  the  same  period  of  1915  in  all  rail,  but 
a  considerable  decrease  in  the  children  handled  over  the  ferries." 

It  would  seem  that  there  was  certainly  a  decrease  in  the  amount  of 
travel  of  children  during  the  summer.  This  does  not  of  necessity,  however, 
mean  that  there  was  a  decrease  in  the  number  of  children  who  left  the  city, 
but  rather  that  when  children  were  taken  from  the  city  they  did  not  return 
until  the  epidemic  was  over,  and  that  there  was  a  decrease  in  the  number  of 
excursions  to  and  from  the  city. 

Convalescent  homes,  because  of  the  edict  against  gathering  of  children 


129 

in  groups,  naturally  received  fewer  cases  of  infants  and  children  than  last 
year.    Alany  of  them,  in  fact,  closed  their  doors. 

Further  effort  was  made  to  obtain  fairly  accurate  data  as  to  the  com- 
parative number  of  infants  who  left  the  city  during  the  summer  of  this 
year,  as  compared  with  that  of  last  year  by  questionnaires  addressed  to 
medical  inspectors  of  the  Department,  who  were  engaged  in  general  practice, 
to  nurses  engaged  in  school  medical  inspection,  and  through  inquiries  made 
of   31    public   school   principals. 

As  a  result  we  have  the  opinion  of  43  physicians  that  there  were  more 
little  children  who  left  the  city  in  1916  than  in  1915,  and  27  who  believed 
the  opposite  to  be  the  case.    Four  thought  there  was  no  difference. 

The  inquiry  of  the  nurses  showed  the  following: 

1915.  1916. 

6.711  8.000  children   under  2   in   families   under   observation. 

5.967— (8970    7.022— (87.9%)   remained  in  the  Citv. 
744— (10.9%,)    982— (12%)    left  the  City. 

The  inquiry  carried  on  through  the  school  principals,  which  involved 

a  study  of  families  with  a  total  of  19,105  children  of  twelve  years  or  over, 

and  2,068  children  two  years  or  under,  seems  to  be  a  better  basis  upon  which 

to  base  an  opinion  than  any  one  of  the  others  above  mentioned,  representing 

a   fair  cross    section  of   the  movements   of    families   with   children   in   the 

populous  Boroughs  of  ^Manhattan  and  Brooklyn.     The  conclusion  is  quite 

definite  that  fewer  children  of  two  years  or  under  left  the  city  in  1916  than 

in  1915. 

(3)     Larger  Xumber  of  A'rzc  York  City  Infants  Dying  Outside  of  the 
City— 

The  third  criticism  advanced,  namely,  that  a  much  larger  number  of 
infants  died  outside  of  the  city  limits  in  1916  than  in  1915  is  not  justified 
by  any  of  the  figures  that  we  have  at  our  command. 

In  the  answers  received  from  the  74  medical  inspectors  (physicians  in 
general  practice;  canvassed,  we  have  reports  of  two  deaths  occurring  out- 
side of  Xew  York  in  1916,  as  against  none  in  1915. 

In  the  study  made  through  the  31  public  school  principals,  the  number 
of  deaths  occurring  outside  of  New  York  City  in  1916  was  eight,  and  in  1915, 
five. 

That  we  might  determine  exactly  the  number  of  children  who  died 
outside  the  city  during  the  summer  months,  whose  deaths  should  be  charged 
against  the  city,  the  Registrar  wrote  to  the  State  Departments  of  Health  of 
New^  York,  Xew  Jersey,  Rhode  Island,  Massachusetts  and  Connecticut, 
asking  them  to  supply  us  with  the  information  called  for  in  a  questionnaire 
which  we  had  prepared,  a  copy  of  which  was  enclosed  with  each  letter. 

The  following  are  the  returns  received  from  the  five  States  mentioned. 
They  do  not  bear  out  the  contention  that  an  unduly  large  number  of  children 
who  were  residents  of  the  city  died  outside  of  its  limits.  In  fact,  the  number 
of  deaths  of  infants  for  one  year  of  age  may  be  considered  small,  the  total 
number  being  16. 


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132 

The  opinion  is  therefore  fairly  borne  out  that  none  of  the  criticisms 
which  have  been  directed  against  the  estimated  reduction  of  infant  mortaHty 
along  the  lines  aforementioned,  namely,  decrease  in  birth  rate,  increased 
exodus  from  the  City,  and  increase  in  number  of  deaths  of  infants  taking 
place  outside  of  the  City,  are  justified,  and  that  the  reduction  in  infant 
mortality  during  the  past  year  was  a  genuine  one,  and  for  reasons  which 
will  be  given  later  in  this  report. 

If  criticism  has  been  directed  against  the  reduction  of  infant  mortahty 
in  general,  it  has  been  particularly  directed  against  the  marked  reduction  in 
the  number  of  deaths  from  diarrhoeal  diseases. 

For  the  first  nine  months  of  1916  there  were  (Table  XXIII — item 
15)  1,965  deaths  from  diarrhoeal  diseases  as  against  2,626  deaths  from  the 
same  cause  for  the  corresponding  period  of  1915,  a  numerical  saving  of  661 
deaths  from  these  diseases. 

This  criticism  was  to  the  effect  that  a  large  number  of  the  deaths 
ascribed  to  infantile  paralysis  were  due  to  diarrhoea,  and  that,  therefore,  the 
number  of  deaths  from  infantile  paralysis  in  infants  should  have  been  less, 
and  correspondingly,  the  number  of  deaths  from  diarrhoea  in  infants  should 
have  been  greater.   . 

The  total  number  of  deaths  from  poliomyelitis  under  one  year  of  age 
during  the  first  three-quarters  of  1916  (Table  XXIII — item  8)  was  395. 
For  these  three  quarters  of  1916  there  were  661  less  deaths  from  diarrhoeal 
diseases  in  infants  than  for  1915. 

If  we  grant,  for  the  sake  of  argument,  that  the  majority,  or  all  of  the 
395  deaths  ascribed  to  infantile  paralysis  in  infants  were,  in  reality,  infantile 
diarrhoea,  there  would  still  be  a  saving  of  266  infant  lives  from  diarrhoeal 
diseases  and  if,  to  satisfy  the  most  exacting  critic,  we  apply  the  infant 
mortality  rate  from  diarrhoeal  diseases,  of  24.5  per  thousand  births,  to  the 
3,841  less  births  which  occurred  during  the  year,  and  subtract  these  93  cases 
from  the  266  above  number  there  would  even  then  be  a  numerical  saving  of 
infants  from  diarrhoeal  diseases  to  the  number  of  173. 

There  is  nothing  unusual  or  unexpected  in  a  marked  reduction  in 
deaths  from  diarrhoea  in  infants.  This  is  rather  to  be  expected.  In  point 
of  fact  the  deaths  of  children  under  one  year  of  age  from  the  four  principal 
causes  for  the  years  1884  and  1914  show  a  per  cent,  reduction  as  follows : 

Contagious  Diseases  88. 7 

Diarrhoeal  Diseases    75 . 7 

Respiratory  Diseases 53 .4 

Congenital    Debility    1.5 

Similarly  it  will  be  seen  that  there  were  fewer  deaths  from  respiratory 
diseases  and  from  contagious  diseases  in  1916  than  in  1915,  so  that  it  is 
evident  that  increased  care  of  infants  has  been  conducted  all  along  the  line 
during  this  year.     (Table  XXIII,  item  15.) 


133 

In  analyzing  the  reduction  in  the  number  of  deaths  from  diarrhoeal 
diseases,  it  may  be  interesting  to  note  the  following : 

Deaths  From  Diarrhoeal  Diseases. 

In  Institu-    In  Dwell- 
Year.  tutions.  ings.  Total. 

1915    919  U07  2fi26 

(35%)  (65%)  (100%) 

1916    668  1,297  1,965 

(34%)  (66%)  (100%) 

Reduction— 1916    251 410 661 

Here  it  will  be  seen  that  a  reduction  took  place  in  institutions  as  well 
as  in  dwellings,  and  that  the  percentage  of  cases  in  institutions  and  dwell- 
ings was  practically  the  same  during  the  two  years. 

If  we  grant  that  there  were  a  certain  number  of  cases  of  diarrhoeal 
disease  diagnosed  as  infantile  paralysis,  it  is  surely  equally  true  that,  par- 
ticularly at  the  beginning  of  the  epidemic,  a  certain  number  of  mild  cases 
of  poliomyelitis  with  gastro-intestinal  symptoms  were  diagnosed  as 
diarrhoea. 

While  it  is  possible  that  there  may  have  been  the  normal  incidence  of 
error  in  the  diagnosis  of  some  of  these  cases,  just  so  it  is  possible  that  cases 
of  diarrhoea  in  this  and  former  years  were  due  to  poliomyelitis ;  but  to  say 
that  the  marked  reduction  in  infant  deaths  from  diarrhoea  was  due  to  the 
listing  of  diagnosis  of  these  cases  as  poliomyelitis  is  unjustified  and  un- 
warranted by  the  facts  of  the  case. 

We  find  that  the  mortality  of  babies  under  two  years  of  age  during  the 
poliomyelitis  epidemic  has  remained  favorable  and  better  than  last  year. 
The  mortality  rate  of  babies  under  two  years  is  based  upon  the  estimated 
population  at  that  age,  and  the  figures  for  1916  (Table  XXIII,  item  6) 
show  a  mortality  rate  of  72.7  as  against  78.5  for  1915. 

In  1916  there  was  a  diminution  in  the  number  of  deaths  under  two 
years  of  age  to  the  extent  of  764  (Table  XXIII,  item  4)  and  this,  despite 
the  fact  that  the  estimated  population  at  that  age  for  1916  exceeded  that  of 
1915  by  almost"  6,000. 

The  number  of  deaths  under  two  years  of  age  from  the  various  groups 
of  diseases  in  children  under  two  years  of  age  (Table  XXIII,  item  16)  was 
less  in  practically  every  instance  than  in  1915,  and  the  mortality  rate  of 
babies  under  two  years  of  age  for  the  various  groups  of  diseases  (Table 
XXIII,  item  18)  was  also  less,  in  most  instances,  than  for  1915. 

During  the  period  of  the  epidemic  (Table  XXIII,  item  25)  it  will  be 
seen  that  the  mortality  rate  of  babies  under  two  years  of  age  from  the  vari- 
ous groups  of  diseases  was  lower  in  1916  than  in  1915. 

1,725  babies  under  two  years  of  age  were  afflicted  with  poliomyelitis, 
or  0.7  per  cent,  of  the  estimated  population  at  that  age,  and  of  these  886,  or  - 
51  per  cent.,  died.     (Table  XXIII,  items  10  and  14.) 


134 

It  will  be  seen  from  the  figures  submitted  that  the  infant  mortality  and 
mortality  of  children  under  two  years  of  age  from  anterior  poliomyelitis 
is  greater  than  at  all  ages,  41  per  cent,  of  those  under  one  year  affected 
dying  and  51  per  cent,  of  those  under  two  years  of  age  affected  dying,  as 
against  a  case  fatality  of  26.3  per  cent,  at  all  ages.  (Table  XXIII,  items  7, 
8,  10,  11,  13  and  14.) 

The  analysis  of  the  deaths  under  one  year  of  age  and  under  two  years 
of  age,  by  boroughs,  shows,  as  noted  in  the  table  below,  that  in  both  instances 
the  percentage  of  deaths  was  largest  in  the  Borough  of  Queens. 

Percentage  of  Deaths  From  Poliomyelitis  by  Boroughs — Under  One  Year  of  Age. 


Borough. 

New  York  City 

Manhattan    

Brooklyn    

The  Bronx   

Queens    

Richmond   


No.  of  Cases      No.  of       Percentage 
Reported.        Deaths.       of  Deaths. 


961 

395 

41.1 

326 

142 

43.5 

460 

179 

38.9 

62 

23 

37. 

97 

44 

45.4 

16 

7 

43.7 

Under  Two  Years  of  Age. 


No.  of  Cases      No.  of       Percentage 

Borough.  Reported.        Deaths.       of  Deaths. 

New  York  City 1,725 

Manhattan    531 

Brooklyn     871 

The  Bronx 104 

Queens 174 

Richmond 45 


886 

51.3 

279 

52.5 

441 

50.6 

47 

45.1 

104 

60.9 

15 

33.3 

Cases  of  Poliomyelitis  Occurring  in  30,575  Babies  Enrolled  at  59  Baby  Health  Stations 
from  June  1,  1916,  to  September  30,  1916. 


Number 

Reported 

111 

Of  Those  III 

Breast      Bottle      Mixed 
Fed          Fed          Fed 

s  Number ' 
Died 

Of  Those  Dying 

Breast      Bottle      Mixed 
Fed          Fed          Fed 

Under  1  year..         115 
1-2  years .....           84 

Totals 199 

41 

7 

48 

54 
28 

82 

20 
49 

69 

36 

23 

59 

6 
6 

22 
4 

26 

8 
19 

27 

Of  those  ill  and  fed  on 
10  cases  given  Grad 

bottled  mi 

le  A  Raw. 
e  A  Pastel 
e  B....... 

Ik: 

Under 
1  Year. 
9 
65 

1-2 

Years. 

1 

137  cases  given  Grad 

arized. . 

72 

3  cases  given  Grad 

3 

135 

Of  those  dying  and  fed  on  bottled  milk:                                                  Under  1-2 

1  Year.  Years. 

0  cases  given  Grade  A  Raw 

49  cases  given  Grade  A  Pasteurized 29  20 

2  cases  given  Grade  B . .  2 

Were   the   children  affected  and   those   dying   well   nourished   or   poorly 
nourished  ? 

Well 137 

Poor   62 

In  how  many  of  the  affected  families  were  there  more  than  one  child 
affected  ? 

(c)   180  families— 1  child— 90%. 

(b)  16  families— 2  children— 8j^%. 

(c)  3  families — 3  children — lj^%. 

What  was  the  sanitary  condition  of  the  homes  in  the  affected  families  ? 

Very  good— 57 ;  Good— 92 ;  Poor— 38 ;  Very  Bad— 12  . 
In  how  many  of  the  affected  families  were  screens  or  mosquito  netting  used  ? 

Yes— 113;  No— 86. 
Can  you  state  in  how  many  of  the  deaths  there  was  diarrhoea  preceding 

death  ?    24. 
How  many  cases  of  poliomyelitis  under  one  year  of  age,  between  1  and  2, 
and  2  to  6  years  of  age  were  listed  in  your  district  during  this  time? 

832  cases  under  1  year — 17^%. 
1,477  cases  1-2  years — 31%. 
2,448  cases  2  to  6  years— 5lJ^%. 

Total— 4,757 

How  many  babies  under  two  years  of  age  were  enrolled  at  your  Station 
during  this  period — June  1st  to  September  30th? 
30,575. 

This  tabulation  shows  that  from  June  1,  1916,  to  September  30,  1916, 
30,575  babies  under  two  years  of  age  received  the  advantages  of  health  sta- 
tion advice  and  care,  and  of  this  number  199  or  .65  per  cent,  were  affected 
with  the  disease.  Of  the  number  affected,  namely,  199,  59,  or  29  per  cent., 
died. 

The  type  of  feeding,  as  noted,  shows  that  babies  on  breast  milk  ex- 
clusively, bottled  milk  exclusively,  or  on  mixed  feeding,  and  given  Grade  A 
raw,  Grade  A  pasteurized,  and  Grade  B  milk,  were  affected  and  succumbed. 

Since  99  per  cent,  of  the  milk  used  for  the  artificial  feeding  of  infants 
in  New  York  City  is  pasteurized,  it  follows  that  so  large  a  per  cent,  of  the 
artificially  fed  children  would  use  pasteurized  milk.  The  fact  that  only 
a  very  small  per  cent,  of  the  affected  ones  were  fed  on  proprietary  foods 
bears  testimony  to  the  value  of  the  educational  campaign  waged  against 
these  foods  by  the  Department  for  many  years. 


CHAPTER   V. 
Insects  as  Carriers  of  Infection. 

An  Entomological  Study  of  the  1916  Epidemic* 

Early  in  August  work  was  undertaken  under  the  direction  of  the 
Health  Department  along  entomological  lines,  with  the  hope  that  either 
positive  or  negative  evidence  might  be  obtained  bearing  on  the  frequently 
repeated  suggestion  that  insects  of  one  kind  or  another  play  a  part  in  the 
spread  of  this  disease.  This  work  is  so  valuable  and  suggestive  that  it  is 
given  practically  as  reported. 
********* 

On  account  of  several  peculiar  facts  connected  with  previous  epidemics 
of  poliomyelitis,  it  has  appeared  possible  that  the  disease  may  not  be  spread 
directly  from  one  person  to  another  like  most  acute  infectious  diseases,  but 
that  it  may  be  dependent  for  its  spread  upon  some  intermediate  agent,  or 
perhaps  upon  some  other  host  or  living  reservoir,  or  possibly  upon  a  com- 
bination of  the  two.  The  most  patent  facts  which  have  suggested  such 
hypotheses  are  those  connected  with  the  epidemiology  of  the  disease. 
Others  made  known  by  laboratory  experimentation  would  seem  to  show 
that  the  disease  is  passed  directly  from  one  affected  human  individual  to 
another  through  immediate  contact,  involving  the  transfer  of  the  virus  from 
the  first  person  to  the  nasal  passage  of  the  second.  That  it  may  be  spread 
through  the  agency  of  dust  or  by  various  other  means  has  also  been  sug- 
gested. 

The  facts  which  lend  color  to  the  belief  that  insects  are  concerned  are 
numerous,  and  some  seem  to  be  of  considerable  importance.  Epidemics 
almost  invariably  begin  during  the  early  part  of  the  summer,  in  late  May 
or  June,  reach  a  climax  during  early  August,  then  rapidly  decline  and 
practically  disappear  in  October.  This  seasonal  incidence  corresponds  with 
that  of  certain  diseases  known  to  be  insect-borne,  and  does  not  occur  with 
other  diseases,  concerning  which  we  know  that  insects  play  no  part  in  their 
transmission.  Certain  enteric  diseases  show  a  marked  summer  increase, 
but  they  also  are  partly  spread  by  flies.  They  never  show  the  almost  com- 
plete winter  disappearance  exhibited  by  poliomyelitis  in  this  country.  The 
disease  has  always  been  regarded  as  more  abundant  under  rural  conditions, 
and  the  present  outbreak,  although  it  has  occurred  in  a  large  city,  has  not 
altered  this  belief,  since  the  Boroughs  of  Richmond  and  Queens,  the  only 
boroughs  which  are  to  any  extent  rural,  have  suffered  more  severely  than 
their  heavily  populated  neighbors.  Insects  of  practically  all  kinds,  except 
those  which  depend  entirely  upon  human  beings  for  their  existence,  are 
more  abundant  in  proportion  to  the  human  population  in  the  country  or  in 

♦By  Prof.  Chas.  T.  Brues,  Professor  of  Economic  Entomolo^,  Harvard  Uni- 
versity and  temporary  Entomologist  to  the  Department  of  Health,  New  York  City. 


137 

small  towns  and  villages.  Cases  of  this  disease  do  not  usually  appear  in 
such  a  way  that  they  can  be  positively  traced  to  contact,  and  many  facts  con- 
nected with  their  spatial  distribution,  as  detailed  in  the  present  report,  seem 
to  be  more  easily  explicable  on  the  basis  of  transfer  by  insects  or  other  ani- 
mals, or  by  both.  As  a  result  of  epidemiological  studies  undertaken  some 
years  ago  in  Massachusetts  (by  Brues),  it  was  suggested  that  the  stable-fly 
(Stomoxys  calcitrans)  might  be  the  insect  agent  by  means  of  which  polio- 
myelitis is  transmitted.  The  following  year  the  disease  was  apparently 
passed  from  monkey  to  monkey  by  the  bites  of  this  fly  in  two  labora- 
tories.* 

But  these  experiments  have  failed  of  further  confirmation,  and  cannot 
now  be  regarded  as  free  from  possible  error.  As  shown  later,  there  is  at 
least  one  other  possible  explanation  of  the  epidemiological  evidence  secured 
both  before  and  during  the  present  epidemic  in  Xew  York  City. 

This  summer's  outbreak  has  offered  so  many  opportunities  for  study 
that  have  not  previously  been  available  that  it  is  of  peculiar  interest  and 
value.  It  has  involved  a  population  living  under  such  entirelv  different 
conditions  from  those  existing  in  places  where  previous  epidemiological 
investigations  have  been  made,  that  much  evidence  of  an  entirely  new 
nature  has  come  to  light. 

On  this  account,  it  has  been  thought  advisable  to  give  a  brief  summary 
of  a  number  of  facts  and  observations  of  more  or  less  general  nature, 
before  dealing  with  the  matter  from  a  purely  entomological  standpoint. 

General   Distributtox   of   Cases   of   Poliomyelitis   in    Greater   New- 
York  IN   Relation  to  a   Possible  Insect   Carrier — Dis- 
tribution IN  THE  Borough  of  AIanhattan. 

By  the  middle  of  September  the  incidence  of  poliomyelitis  reached  a 
very  little  over  one  per  thousand  of  population  (1.01)  in  the  Borough  of 
^Manhattan,  thus  falling  considerably  short  of  that  in  Brooklyn  and  Staten 
Island,  which  will  be  considered  separately.  A  glance  at  a  spot  map  upon 
which  the  Manhattan  cases  have  been  marked  shows  a  distribution  and 
abundance  which  would  seem  at  first  glance  to  correspond  quite  closely 
with  the  general  distribution  of  the  human  population  of  the  island.  On 
the  east  side  below  34th  Street  and  above  Brooklyn  Bridge  to  the  east  of 
the  Bowery  and  Third  Avenue,  there  have  been  a  great  many  cases,  and 
the  map  is  thickly  spotted  in  conformity  with  the  great  density  of  popula- 
tion in  this  portion  of  the  City.  To  the  west  of  this,  extending  from  West 
Broadway  between  Canal  and  4th  Streets  northwestward  between  Bedford 
at  West  4th  Street  to  Grosvenor  Street  and  North  River,  is  another  area 
with  a  large  number  of  cases.  This  also  corresponds  roughly  to  a  heavily 
populated  area,  except  that  this  group  of  cases  extends  nearer  to  North 

*  By  Rosenau  and  Brues  at  the  Harvard  Medical  School  in  Boston,  and  by  Ander- 
son and  Frost  at  the  Federal  Hygienic  Laboratory  in  Washington. 


138 

River  and  further  south  along  West  Broadway  than  might  be  expected  on 
the  basis  of  population.  On  the  middle  west  side,  between  West  23d  Street 
and  West  32d  Street,  are  a  number  of  well-defined,  small  foci  which  do 
not  correspond  to  a  densely  populated  area.  Again,  west  of  Broadway, 
between  45th  and  70th  Streets,  a  great  many  cases  have  occurred  over  a 
large  area  which  does  not  support  a  very  dense  population.  On  the  upper 
east  side  the  abundance  of  the  disease  corresponds  well  with  the  compara- 
tive density  of  the  population,  as  there  is  a  large  number  of  cases  above 
95th  Street,  the  incidence  dropping  off  above  119th  Street  and  124th  Street, 
in  close  accord  with  the  density  of  the  population.  On  the  upper  west  side, 
between  Manhattan  Street  and  West  135th  Street,  is  a  large,  well-defined 
focus  which  does  not  in  any  way  correspond  to  a  thickly  populated  area. 

In  general,  over  the  whole  Borough  of  Manhattan  the  cases  have  been 
grouped  in  a  band  of  Varying  width,  nearly  always  contiguous  to  the  water 
fronts  of  the  East  and  North  Rivers,  with  a  narrow  portion  of  the  island 
almost  entirely  unaffected.  This  is  particularly  true  south  of  Central  Park, 
the  difference  being  less  marked  north  of  the  park.  It  is  thus  seen  that 
with  some  striking  exceptions  there  have  been  a  far  greater  number  of 
cases  per  acre  in  thickly  populated  areas,  with  an  evident  tendency  to 
heavier  infection  irrespective  of  density  of  population  along  the  sides  of 
the  island  near  the  water  fronts  of  both  the  East  and  North  Rivers. 

When  certain  areas  are  examined  more  in  detail,  it  is  seen  that  they 
throw  further  light  on  the  distribution  of  cases  in  relation  to  population 
and  to  other  possible  factors. 

Lower  East  Side — 

The  portion  of  Manhattan  east  of  Catharine  Street,  the  Bowery  and 
Third  Avenue  south  of  14th  Street  includes  a  population  of  over  half  a 
million  persons.  In  practically  no  considerable  part  of  this  area  does  the 
population  fall  below  300  persons  per  acre,  and  in  over  half  of  the  acre  it 
ranges  from  500  to  over  800  persons  per  acre.  Most  of  the  inhabitants  are 
housed  in  five  or  six  story  tenement  houses,  which  line  the  streets  in 
almost  unbroken  series.  There  are  large  numbers  of  food-shops  and  other 
small  stores  of  various  kinds  on  the  street  floors  of  these  tenements,  and 
the  entire  child-population  necessarily  spends  its  time  upon  the  streets,  the 
entries  to  buildings,  and  the  open  spaces  which  serve  as  back  yards  to  the 
tenements.  Under  such  conditions  it  is  evident  that  the  opportunities  for 
the  spread  of  contagious  diseases  must  be  great,  since  the  number  of  healthy 
children  that  may  come  in  contact  with  one  harboring  a  contagious  disease 
is  greatly  enhanced  by  the  congestion  of  the  limited  areas  in  which  the 
children  play.* 


*  As  the  populations  of  the  small  areas  here  referred  to  have  been  taken  from  the 
census  of  1910,  figures  from  the  same  census  have  been  used  for  comparison  with  the 
city  as  a  whole.  The  different  rates  of  growth  in  various  parts  of  the  city  cannot 
have  been  sufficiently  different  to  change  the  incidence  rates  appreciably. 


139 

As  has  been  said,  the  smaller  sections  of  this  east  side  area  represent 
several  distinctly  different  densities  of  population,  which  may  be  grouped 
as  follows : 

Area  with  Over  800  Persons  Per  Acre. 

.  Cases  of  Rate 

^'^^^-  Population.  Poliomyelitis.  Per  1,000. 

51  acres  44,500  29  0  6 

416    acres  37,700  24  0  6 

52  acres  42,000  30  0.7 

Total 124,200  83  0^  rate 

Per    acre    0.55 

Area  with  from  600-799  Persons  Per  Acre. 

54  acres    37,700  32  0.8 

47   acres 30,400  16  0.5 

40    acres    25,100  19  0.7 

36    acres    23,100  18  0.7 

Total 116,300  85  0.73  rate 

Per  acre    0.48 

Area  with  from  500-599  Persons  Per  Acre. 

56  acres  28,600  18  0.6 

6Z  acres 34.900  66  1.9 

42  acres  22,800  25  1.1 

43  acres 25,700  43  \-7 

43  acres 23,500  31  1.3 

Total 135,500  183  1.35  rate 

Per  acre    0.74 

Area  with  from  400-499  Persons  Per  Acre. 

58  acres    24,400  43  1.7 

52  acres 25,700  22  0.8 

43  acres    18.800  21  1.1 

52  acres    25,500  15  0.6 

39  acres    16,300  16  1.0 

55  acres    27,100  42  1.5 

Total 137,800  159  1.15  rate 

Per  acre    0.53 

Area  with  from  100-135  Persons  Per  Acre. 

47  acres  5,600  6  1.0     rate 

Per  acre    0.13 

From  this  table  it  will  be  seen  the  area  of  densest  population  has  had 
a  very  decidedly  lower  incidence  than  any  of  the  more  thinly  populated 
sections  in  this  part  of  the  City.  As  a  matter  of  fact,  the  highest  incidence 
has  been  in  the  group  of  500-599  persons  per  acre,  although  this  group  has 
not  had  a  noticeably  greater  incidence  except  in  one  small  part  than  the 
group  of  400-499  persons  per  acre.  Thus  the  only  direct  relation  of  density 
of  population  to  incidence  of  poliomyelitis  has  been  an  inverse  one  in  this 
district,  if  the  incidence  be  related  to  density  at  all,  and  this  agrees  with 
the  general  tendency  noted  elsewhere  for  sparsely  settled  regions  to  be 
more  severely  affected. 

If  in  this  same  district,  we  compare  the  incidence  with  the  area,  i.  e., 
the  incidence  per  acre,  we  find  that  it  is  more  nearly  uniform  than  it  is  in 


140 

relation  to  human  population  (with  the  exception  of  one  small  area  with 
only  115  persons  to  the  acre),  since  this  incidence  varies  only  from  .48  to 
.74  per  acre.  This  is  suggestive  of  the  possibility  that  some  other  popula- 
tion than  the  human  one  may  take  part  in  determining  the  incidence  of  the 
disease  in  children.  With  this  in  mind,  if  we  compare  the  incidence  in  the 
densely  populated  sections  (see  Map  1)  contiguous  to  the  water  front  with 
the  remaining  sections,  we  find  that  it  is  as  follows : 

Cases  of  Incidence  Incidence 

Poliomyelitis.  Population.       Per  1,000.  Acres.     Per  Acre. 


Contiguous  to  water  front  213  145,400  1.46  313  .68 

Removed   from  water  front  318  388,300  0.81  615  .51 

I 

This  indicates  that  the  incidence  has  been  much  higher  along  the  water 
front,  both  in  relation  to  population  and  in  relation  to  the  actual  area  of 
the  sections,  corroborating  the  general  impression  that  there  has  been  a 
well-marked  tendency  for  the  cases  to  group  themselves  along  the  water 
front  throughout  the  City.  In  this  particular  instance  none  of  the  sections 
are  far  removed  from  the  docks  which  line  the  river,  although  the  strip 
selected  for  comparison  lies  directly  adjacent  to  the  water  while  the  others 
do  not.  This  grouping  is  also  suggestive  of  a  factor  aside  from  human 
population  and  social  conditions.  It  is  at  least  not  contrary,  but  is  wha|: 
might  be  expected  if  the  rat  .should  bear  some  relation  to  poliomyelitis,  and 
might  possibly  be  explained  on  such  an  hypothesis. 

On  the  other  hand,  for  no  reason  which  seems  apparent,  the  three  sec- 
tions (see  Map  1)  which  mark  the  northern  limit  of  the  thickly  populated 
district  between  9th  and  14th  Streets,  all  have  a  very  high  incidence : 

Cases  Incidence 

of  Poliomyelitis.      Population.  Per  1,000  Acres.    Incidence  Per  Acre. 

85  68,000  1.25  129  .66 

It  does  not  equal  that  of  the  sections  along  the  water  front,  but  is, 
nevertheless,  far  in  excess  of  the  other  sections  removed  from  the  water 
front.  Whether  this  strip  supports  a  larger  rat  population  than  its  neigh- 
bors on  the  south  would  be  difficult  to  say.  In  so  far  as  insects  of  any  kind 
are  concerned,  it  seems  impossible  to  understand  the  peculiar  distribution 
of  poliomyelitis  in  this  district  on  the  basis  of  their  comparative  abundance. 
It  is  true  that  the  stable  fly  is  especially  abundant  along  the  water  front  on 
account  of  the  large  amount  of  trucking  which  goes  on  there,  but  it  is  not 
noticeable  that  the  disease  has  spread  along  the  streets  which  are  most 
generally  used  for  teams.  The  disease  should  follow  these  streets  if  the 
stable  fly  were  concerned,  as  this  insect  migrates  most  abundantly  along 
thoroughfares  through  which  many  horses  pass  regularly.  That  it  has  not 
followed  these  streets  would  therefore  seem  to  be  significant,  especially  in 


141 

view  of  its  greater  prevalence  along  the  northern  strip  of  this  district  where 
there  is  no  more  traffic  than  in  the  other  portions  further  south.  One  fact 
which  seems  perfectly  clear  is,  that  under  urban  conditions  of  this  type 
where  large  numbers  of  persons  are  crowded  in  congested  dwellings,  there 
is  no  tendency  toward  a  rise  in  the  incidence  of  poliomyelitis.  This  is 
abundantly  shown  by  the  details  which  have  been  cited  in  the  preceding 
pages,  and  offers  poor  support  to  the  view  that  these  cases  have  been  con- 
tracted as  a  result  of  contact  with  children  suffering  from  the  disease,  or 
as  a  result  of  contact  with  healthy  carriers  of  the  poliomyelitis  virus. 

Lower  West  Side — 

Considerable  interest  attaches  to  a  small  group  of  cases  on  and  about 
Greenwich  Street  just  north  of  Battery  Park.  Only  about  a  dozen  of  cases 
have  appeared  here,  the  first  during  the  last  week  in  July,  and  the  others 
in  irregular  sequence  during  August  into  September.  This  focus  has 
remained  entirely  isolated  from  any  others,  although  it  is  not  separated 
from  them  by  a  space  devoid  of  dwelling  houses.  Its  direct  connection  with 
a  large  focus  near  the  West  132d  Street  docks  is,  however,  evident  since 
there  are  boats  plying  daily  between  these  uptown  docks  and  those  directly 
adjacent  to  the  Greenwich  Street  focus.  These  boats  might  easily  serve 
for  a  trans ferance  of  rats,  but  their  passengers  come  from  widely  separated 
parts  of  the  City,  and  not  particularly  from  affected  regions  about  Green- 
wich Street  or  West  132d  Street. 

Middle  West  Side — 

Although  the  area  to  the  south  of  West  33d  Street  and  West  of  Sixth 
Avenue  has  not  suffered  severely,  it  shows  a  very  interesting  distribution  of 
cases  into  several  small,  well-defined,  and  more  or  less  isolated  foci,  each 
of  which  includes  only  a  few  cases  restricted  to  a  single  block  or  to  two 
adjacent  ones.  The  grouping  and  form  of  these  very  small  foci  is  of  such 
particular  interest  that  it  is  dealt  with  on  another  page. 

Further  uptown  there  is  a  noticeable  concentration  of  cases  in  the 
district  adjoining  the  stock  yards  in  the  vicinity  of  West  68th  Street.  This 
group  is  quite  discrete,  but  the  cases  are  not  so  closely  associated  as  in  a 
number  of  other  districts.  As  the  group  is  in  proximity  to  the  stock  yards, 
there  is  here  an  especially  great  opportunity  for  both  rats  and  the  various 
bloodsucking  flies,  such  as  the  stable  fly  and  the  members  of  the  genus 
Tabanus,  which  are  associated  with  the  larger  domesticated  animals. 

Upper  West  Side — 

An  extremely  interesting  group  of  cases  has  developed  near  North 
River  between  West  126th  Street  and  West  142d  Street,  most  concentrated 
(see  Map  2)  between  West  130th  Street  and  West  132d  Street.  In  this 
area  by  the  middle  of  September  42  cases  had  appeared  and  later  several 
more  had  been  reported.    The  density  of  the  population  is  very  much  less 


142 

than  in  the  district  on  the  lower  East  Side,  which  had  been  referred  to  on 
a  previous  page.  It  ranges  from  83-140  persons  per  acre,  with  an  incidence 
of  poliomyelitis  of  from  0.8  to  3.6  per  thousand  of  population,  as  shown  in 
the  following  table: 

Density  Per.    Number  Rate  Rate 

Area.  Population.  Acre  of  Cases.     Per  1,000.      Per  Acre. 

47  acres  3,900  83  8  2.0  .17 

50  acres  6,800  137  25  3.6  .50 

47  acres  3,500  176  '     3  0.8  .06 

47  acres  6,600  140  6  0.9  .12 

Total   20,800  42  2.0  .22 

I 

It  thus  appears  that  the  incidence  in  this  area  of  comparatively  sparse 
population  has  greatly  exceeded  that  on  the  lower  East  Side,  being  as  a 
matter  of  fact  almost  double,  showing  again  very  evidently  that  maximum 
incidence  under  these  quite  urban  conditions  is  not  a  function  of  the  popu- 
lation density.  The  same  fact  is,  of  course,  evident  by  the  very  irregular 
distribution  of  cases  in  practically  every  locality  affected,  but  on  account  of 
the  great  number  of  factors  which  may  be  involved,  it  is  difficult  to  draw 
conclusions  from  this.  It  may  be  said,  however,  that  it  does  not  accord 
well  with  what  might  be  expected  if  some  actively  flying  insect  were  con- 
cerned in  the  dissemination  of  poliomyelitis.  It  does  resemble  at  first  blush 
foci  which  have  developed  in  the  City  as  a  result  of  carrier  typhoid  infec- 
tion, but  many  of  these  poliomyelitis  foci  cannot  be  associated  with  any 
probable  carrier,  and  besides,  the  distribution  of  the  whole  epidemic  corre- 
sponds in  no  way  to  that  of  typhoid.  This  matter  is  dealt  with  on  another 
page. 

There  have  been  other  smaller,  and  a  number  of  larger,  sparse  groups 
of  cases  in  Manhattan,  but  most  of  them  do  not  show  a  sufficient  size  or 
concentration  to  make  it  evident  that  they  represent  really  definite  dififer- 
ences  in  incidence.  Irregular  population  distribution  and  many  minor 
factors  might  so  easily  account  for  them  that  they  can  hardly  form  the  basis 
for  generalizations. 

Distribution  in  the  Borough  of  The  Bronx — 

The  number  of  cases  in  The  Bronx  has  been  comparatively  few  and 
the  incidence  correspondingly  much  lower  than  that  in  other  boroughs. 
There  have  been  no  foci  of  any  considerable  size  or  density,  although  earlier 
in  the  course  of  the  epidemic  it  seemed  probable  that  several  were  de- 
veloping. These  proved  to  be  evanescent,  however,  and  later  cases  have 
produced  a  quite  even  distribution  over  the  area  north  of  the  Harlem  River 
and  between  the  line  of  the  New  York  Central  on  the  west  and  the  New 
York,  New  Haven  and  Hartford  on  the  east  as  far  north  as  Bronx  Park 
and  Fordham  University.     Along  its  western  boundary  this  area  has  ex- 


143 

tended  a  short  distance  west  of  the  railroad,  but  the  western  part  of  The 
Bronx  has  been  practically  free  from  infection — in  fact  remained  almost 
entirely  so  until  very  late  in  the  course  of  the  epidemic.  This  western 
section  is  very  much  more  sparsely  settled  than  the  eastern  one  which  suf- 
fered from  poliomyelitis,  and  is  quite  generally  separated  from  it  by  much 
nearly  vacant  land.  Nevertheless,  it  has  continual  intercourse  with  the 
City.  We  could  find  no  lack  of  insects  in  this  district — in  fact  conditions 
are  favorable  for  the  production  of  our  common  bloodsucking  flies.  The 
land  is  considerably  elevated  and  thus  well  separated  from  the  railroad  that 
skirts  the  Harlem  River  Canal.  It  would,  therefore,  appear  unlikely  for 
rats  to  reach  it  from  the  railroad  on  account  of  its  sharp  elevation  on  this 
side.  Also,  the  region  is  devoted  almost  exclusively  to  the  homes  of  the 
well-to-do,  who  remove  their  children  from  the  City  for  the  entire  summer. 

Distribution  in  the  Borough  of  Brooklyn — 

Since  the  present  epidemic  first  gained  serious  proportions  in  Brooklyn, 
especial  interest  naturally  centres  upon  its  behavior  in  this  borough.  The 
incidence  has  been  considerably  over  twice  that  for  Manhattan,  and  the 
disease  has  appeared  abundantly  in  districts  of  several  types.  As  it  has 
also  showed  a  more  or  less  constant  movement  or  shifting  from  the  first 
centre,  the  course  of  the  disease  in  Brooklyn  offers  much  valuable  infor- 
mation. 

In  the  immediate  vicinity  of  its  origin  in  Brooklyn,  the  epidemic  did 
not  gain  the  intensity  which  it  showed  some  time  later  in  adjoining  districts 
into  which  it  had  spread  in  the  meantime.  There  has  been,  however,  a 
great  number  of  cases  in  the  district  into  which  the  northern  end  of  the 
Gowanus  Canal  extends,  an  area  which  is  roughly  coincident  with  the  first 
indications  of  an  epidemic.  Here  the  greatest  number  of  cases  have 
appeared  in  the  district  west  of  Third  Avenue,  north  of  Third  Street  and 
south  of  Wyckoff  Avenue.  They  have  extended  to  the  East  River  in 
decreased  numbers  over  a  narrow  space,  and  then  in  greatly  increased 
abundance  along  the  region  adjoining  the  water  front  from  Joralemon 
Street  to  Hamilton  Avenue.  This  portion  of  Brooklyn  is  rather  thickly 
settled,  but  the  dwellings  are  to  a  great  extent  old  wooden  houses  that  do 
not  contain  a  great  number  of  families.  On  the  whole,  it  is  eminently 
suited  to  support  a  large  population  of  rats  and  a  considerable  one  of  house 
flies  and  stable  flies,  the  former  on  account  of  its  proximity  to  the  water 
front,  its  old  houses,  and  the  latter  also  by  reason  of  its  numerous  stables. 
On  the  whole,  the  sanitary  conditions  under  which  its  inhabitants  live  are 
bad,  partly  from  necessity  due  to  the  surroundings  and  partly  from  lack 
of  desire  for  cleanliness. 

To  the  south  of  this  part  of  the  borough,  and  separated  by  a  narrow 
strip,  is  another  area  in  which  a  great  number  of  cases  have  occurred. 
This  follows  quite  closely  along  the  water  front  and  extends  as  far  as  60th 
Street,  with  only  one  or  two  insignificant  breaks.     The  northern  part  of 


144 

this  area  is  composed  of  blocks  which  contain  tenements  that  house  a  large 
number  of  families,  and  consequently  this  part  has  had  more  cases  in  pro- 
portion to  its  area  than  the  part  further  south,  which  includes  a  great 
number  of  smaller  houses!  These  smaller  houses  are  in  many  cases  old 
wooden  buildings,  but  many  are  of  far  better  stone  and  brick  construction, 
although  nearly  all  were  built  many  years  ago.  A  few  newer  apartment 
buildings  of  small  or  moderate  size  are  scattered  through  this  southern  part 
of  the  district.  Although  of  far  better  appearance  in  nearly  every  respect, 
much  poliomyelitis  has  appeared  here.  It  has  undoubtedly  shown  a  prefer- 
ence for  the  older  wooden  houses  but  has  nevertheless  occurred  quite  com- 
monly in  the  neatest  of  the  small  brownstone  and  brick  houses.  On  the 
whole,  the  probability  of  a  considerable  rat  population  here  would  seem 
less  likely  than  in  almost  any  other  part  of  the  City  in  which  poliomyelitis 
has  appeared  abundantly. 

In  proportion  to  its  resident  population.  Coney  Island,  which  forms  the 
southern  end  of  Brooklyn,  has  suffered  quite  heavily.  Here  there  have  been 
two  more  or  less  clearly  defined  foci  with  a  few  more  scattered  cases.  The 
greater  part  of  these  has  been  in  old.  houses  under  bad  sanitary  conditions, 
and  neither  rodents,  flies  or  insects  would  be  excluded. 

The  most  extensive  group  of  cases  in  Brooklyn  was  in  an  irregular 
area.  The  upper  arm  extends  from  East  River  between  the  Williamsburg 
Bridge  and  Greenpoint  Park  eastward  to  somewhat  beyond  Myrtle  Avenue. 
The  lower  arm  drops  considerably  to  the  south  of  Myrtle  Avenue  as  it 
approaches  the  west  and  stops  short  just  before  reaching  the  Navy  Yard. 
The  whole  group  is  more  or  less  distinctly  separated  from  the  foci  further 
south,  but  is  connected  by  a  narrow  group  that  extends  along  the  southern 
boundary  of  the  Navy  Yard,  and  then  suddenly  enlarges  to  occupy  a  con- 
siderable area  about  the  approaches  to  the  Brooklyn  and  Manhattan  Bridges. 
Below  this,  however,  there  is  a  distinct  break  of  fully  a  quarter  of  a  mile 
before  the  limits  of  the  first  Brooklyn  area  mentioned  is  reached.  The 
space  between  the  arms  of  the  above-mentioned  include  the  area  bounded 
by  Division  Avenue,  Broadway,  Wallabout  Street  and  the  Navy  Yard. 
Within  this  space  only  a  comparatively  few  scattered  cases  have  occurred. 
This  section  includes  much  of  the  older,  more  thickly  settled  portions  of 
Brooklyn,  and  supports  a  rather  uniformly  dense  population.  The  incidence 
of  poliomyelitis  has  been  very  high,  much  higher  than  in  the  densely  popu- 
lated sections  of  the  lower  East  Side  in  Manhattan,  although  the  inhabitants 
do  not  live  under  such  conditions  of  congestion  as  their  neighbors  across 
the  river. 

The  last  distinct  group  in  Brooklyn  to  be  mentioned  is  one  which  em- 
braces the  Hebrew  section  commonly  known  as  Brownsville.  Here  the 
incidence  has  not  been  so  high  as  might  have  been  expected  from  the  con- 
ditions which  prevail.  The  population  is  sparser  than  in  the  last-mentioned 
section,  but  not  sufficiently  so  to  account  for  the  great  scattering  of  the 


145 

cases.  This  group  is  quite  sharply  limited  to  the  north  by  Atlantic  Avenue, 
for  above  this,  in  the  better  section,  a  smaller  number  of  cases  have 
occurred.* 

From  this  it  can  be  seen  that  the  distribution  of  the  cases  in  Brooklyn 
has  been  apparently  much  more  erratic  than  in  Manhattan.  Practically  all 
of  the  water  front  which  supports  large  shipping  activities  has  had  a  dense 
fringe  of  cases  in  the  residential  blocks  that  extend  inland.  In  this  respect 
it  has  shown  a  more  or  less  close  agreement  with  Manhattan.  About 
Gowanus  Canal  the  district  affected  has  extended  inward  further,  possibly 
through  some  influence  exerted  by  the  canal.  The  large  area  northeast  of 
the  Navy  Yard  adjoins  the  water  only  for  a  very  small  part  of  its  extent, 
and  extends  inland  over  an  area  of  closely  built-up  blocks  of  mainly  old 
houses.  In  Brownsville  far  removed  from  the  water  front  the  incidence 
has  been  lower  than  might  otherwise  has  been  expected,  from  comparison 
with  other  parts  of  Brooklyn.  On  account  of  its  strict  adherence  to  the 
environmental  conditions  mentioned,  it  seems  evident  that  the  method  of 
propagation,  if  it  be  other  than  chance  contact  of  individuals,  must  depend 
upon  something  correlated  with  such  conditions.  The  proximity  of  so 
many  affected  areas  to  the  water  front,  the  exceptions  being  in  two  closely 
populated  districts  of  which  the  one  farther  removed  from  the  water  front 
suffered  less  than  was  expected  from  living  conditions,  both  point  to  some 
population  other  than  the  human  one.  No  insect  which  I  have  observed 
abundantly  seems  to  fulfill  these  conditions,  although  the  epidemiological 
conditions,  including  the  spread  in  the  Brooklyn  areas,  would  seem  to  be 
explicable  with  little  difficulty  by  rat  prevalence  and  migration. 

Distribution  in  the  Borough  of  Richmond — 

Staten  Island,  the  least  urban  of  the  Boroughs  of  Greater  New  York, 
has  suffered  very  severely  from  poliomyelitis  during  the  present  outbreak. 
With  a  population  of  less  than  100,000  persons  and  over  290  cases,  the 
incidence  has  been  approximately  3  per  thousand.  This  is  particularly  inter- 
esting since  it  gives  an  opportunity  to  compare  the  same  epidemic  under 
conditions  prevailing  in  the  lower  East  Side,  probably  the  most  congested 
district  in  the  world,  with  Staten  Island,  a  small  city  with  attendant  villages 
and  countryside.  The  triply  greater  incidence  in  Staten  Island  bears  our 
previous  experience  that  poliomyelitis  is  a  rural  disease,  more  prevalent  in 
thinly  settled  districts  than  in  cities.  This  fact  of  course  suggests,  as  it 
has  in  other  parts  of  our  own  country  and  abroad,  that  the  dissemination 
of  the  infective  virus  is  dependent  upon  some  insect  or  other  animal  popu- 
lation which  is  uniformly  more  abundant  in  proportion  to  the  human 
population  under  rural  conditions  than  it  is  in  cities.  An  examination  of 
the  island  from  an  entomological  standpoint  has  unfortunately  failed  to 
disclose  much  further  information  of  apparent  value.  The  cases  are 
grouped  into  what  may  be  conveniently  classed  as  four  types.     Many  are 

*  Brownsville  was  infected  in  the  previous  epidemic  of  1907. 


146 

in  the  older  and  more  thickly  settled  parts  of  the  island.  They  have  been 
as  a  rule  in  the  poorer  sections  and  streets  and  along  the  water  front,  the 
latter  in  this  case  contiguous  to  the  most  thickly  settled  parts.  Others  have 
been  in  suburban  residence  districts  of  well-built,  well-kept  and  separated 
houses.  Others  have  been  scattered  throughout  the  thinly  settled  parts  of 
the  island,  usually  along  or  not  far  removed  from  the  main  thoroughfares 
which  traverse  it.  A  few  have  been  at  summer  camps  where  large  numbers 
of  city  people  are  crowded  together  in  small  one  or  two  room  tent  houses 
or  "  bungalows."  These  camp  houses  have  been  comparatively  free  from 
poliomyelitis,  considering  their  quite  considerable  population.  They  are 
built  directly  upon  the  sandy  beaches,  very  generally  raised  from  the  ground 
by  wooden  blocks  or  short  pillars,  and  this,  in  connection  with  the  fact  that 
these  camps  are  vacant  during  the  winter,  must  reduce  the  rat  population 
very  greatly.  If  this  condition  be  compared  with  that  in  the  section  of 
Coney  Island  which  has  sufTered,  it  is  seen  that  prevalence  of  rats  is  evi- 
dently in  these  two  cases  parallel  with  that  of  poliomyelitis.  In  the  two 
places  flies  of  the  common  kinds  do  not  appear  to  be  noticeably  different 
in  abundance. 

The  general  distribution  in  Staten  Island  is  so  similar  to  that  already 
observed  during  many  epidemics  in  small  cities  with  their  surrounding  vil- 
lages and  scattering  houses,  that  I  have  been  unable  to  find  any  striking 
peculiarities.  Some  cases  have  been  almost  entirely  isolated,  but  in  many 
instances  there  have  been  groups  of  two  or  three  nearly  simultaneous  cases. 
Some  of  these  have  been  in  single  houses  or  families,  21  secondary  and 
tertiary  cases  in  all,  or  over  7  per  cent,  of  the  total  290  cases.  This  per- 
centage of  secondary  cases  in  Staten  Island  is  at  least  double  that  in  Greater 
New  York  as  a  whole  and  is  difficult  to  understand  on  the  basis  of  infection 
from  person  to  person,  since  there  cannot  be  twice  the  opportunity  for  such 
contact  in  Staten  Island.  This  excess  should  be  anticipated,  however,  in 
the  case  of  transmission  by  insects  infected  from  a  non-human  host,  if  their 
population  is  greater  in  proportion  to  the  human  population.  It  would 
result  in  a  greater  number  of  infective  agents  at  work  among  a  smaller 
number  of  persons,  so  grouped  that  the  houses  or  family  stands  out  as  a 
definite  spatial  group  liable  to  multiple  infection.  Such  house  or  family 
isolation  of  this  type  does  not  occur  in  the  other  boroughs  to  any  extent, 
and  we  do  not  find  so  many  double  or  triple  cases  in  them. 

The  other  groups  of  two  or  three  cases,  mentioned  above  as  near 
together  but  not  in  the  same  house,  have  appeared  in  a  number  of  more  or 
less  isolated  spots  on  the  island.  They  would  appear  to  be  homologous  to 
the  similar  pairs  or  small  groups  that  are  continually  cropping  out  in  the 
thickly  settled  boroughs,  due  apparently  to  the  appearance  of  some  infective 
agent.  The  distance  traveled  by  the  agent  cannot  be  traced  under  the  com- 
plicated conditions  prevailing  in  the  other  boroughs,  but  in  Richmond,  as 
in  other  sparsely  settled  districts,  the  distance  possible  in  a  short  space  of 


147 

time  is  evidently  at  least  several  miles.  This  is,  of  course,  easily  explained 
either  by  the  possible  advent  of  a  human  carrier,  or  by  the  appearance  of 
some  insect  or  rodent,  since  the  same  method  of  spread  has  been  observed 
vi^ith  yellow  fever  and  bubonic  plague  when  they  have  spread  by  introduc- 
tion into  places  where  they  are  not  endemic* 

As  the  Staten  Island  outbreak  is  being  very  carefully  studied  and  tabu- 
lated by  others,  their  findings  may  show  that  some  of  my  own  brief  observa- 
tions have  been  misleading.  At  any  rate  the  behavior  of  the  disease  on 
Staten  Island  has  been  surprisingly  like  its  previous  behavior  in  other  small 
cities,  and  the  divergencies  which  appear  between  this  borough  and  the 
others  of  Greater  New  York  consequently  become  of  enhanced  value. 

Distribution  in  the  Borough  of  Queens — 

The  entomologist  has  not  given  much  attention  to  this  borough,  partly 
as  it  did  not  seem  to  exhibit  conditions  strikingly  diflerent  from  those 
observed  in  other  parts  of  the  City  and  partly  because  of  the  impossibility 
of  covering  such  a  large  area  with  any  degree  of  completeness  in  the  limited 
time  available.  One  well-defined  focus  of  about  twenty  cases  in  Long 
Island  City  was  visited.  This  locality  is  very  much  like  those  re- 
ferred to  in  the  Borough  of  Brooklyn,  in  the  region  of  the  Gowanus 
Canal.  It  is  directly  on  the  water  front,  adjacent  to  the  yards  of 
the  Long  Island  Railroad,  and  near  Newtown  Creek.  The  area  occupied 
is  very  closely  isolated  from  any  other  focus,  and  the  cases  appeared  over 
a  considerable  period  during  July  and  early  August.  Over  half  (11  cases), 
however,  were  reported  during  a  single  week  following  the  middle  of  July, 
The  course  of  cases  in  this  focus  has  followed  the  usual  rule  observed  in 
others;  an  isolated  case,  one  or  two  more  coincident  or  a  few  days  later, 
after  a  couple  of  weeks  a  considerable  proportion  of  the  entire  number, 
then  a  gradually  dwindling  scattering  of  cases. 

One  other  locality  in  the  Borough  of  Queens  which  suffered  rather 
heavily  was  the  extensive  summer  colony  which  extends  along  Rockaway 
Beach.  Many  cases  appeared  here  in  three  or  four  poorly  defined  groups. 
Here  the  conditions  are  similar  to  those  of  Coney  Island  except  that  the 
houses  are  of  better  construction  and  in  somewhat  better  condition.  They 
are,  however,  old  and  not  of  the  small  type  with  open-air  space  below  men- 
tioned in  connection  with  Staten  Island. 

Distribution  Summarized — 

In  reviewing  the  material  presented  in  the  present  section  of  this  report 
the  following  facts  seem  worthy  of  repetition : 

In  general  the  cases  of  poliomyelitis  have  grouped  themselves  more  or 
less  in  proportion  to  varying  density  of  population  in  different  portions  of 

*  A  small  epidemic  of  yellow  fever  on  the  Island  of  Barbadoes  described  by  Boyce, 
and  several  small  outbreaks  of  plague  in  Sydney,  N.  S.  W.,  are  extremely  interesting 
in  comparison  with  the  present  poliomyelitis  epidemic  in  Staten  Island. 


148 

the  various  boroughs.  There  has  nevertheless  been  a  distinct  tendency 
toward  a  higher  incidence  in  sections  directly  adjoining  Brooklyn. 

Great  density  of  population  does  not  tend  toward  a  higher  incidence 
of  the  disease.  This  is  shown  particularly  from  a  comparison  of  the  East 
Side  tenement  section  with  other  parts  of  Manhattan. 

Numerous  areas  have  been  practically  free  from  infection,  while  others 
of  apparently  similar  character  and  human  population  have  developed 
extensive  foci  of  poliomyelitis. 

Staten  Island  has  sufifered  more  severely  than  any  other  borough  except 
Queens,  showing  the  usual  tendency  of  poliomyelitis  to  affect  rural  districts 
more  heavily  than  cities.  The  high  incidence  in  Queens  was  reached  during 
the  last  weeks  of  the  epidemic,  as  the  disease  spread  to  the  more  thinly 
populated  sections. 

Many  facts  of  distribution  and  general  prevalence  suggest  that  the 
disease  is  at  least  to  som.e  extent  dependent  upon  some  population  other 
than  the  human  one  for  its  spread.  Insects  migrating  by  themselves,  or  on 
the  body  of  some  animal  host  like  a  rat,  might  easily  account  for  the  facts 
dealt  with  in  this  section  of  the  report. 

Distribution  of  Cases  in  Relation  to  the  Immediate  Neighborhood. 

In  referring  to  the  general  proportions  of  the  epidemic  in  the  several 
boroughs,  and  in  the  smaller  areas  where  definite  foci  have  developed,  it 
has  been  impossible  to  deal  with  a  great  many  facts  which  have  a  bearing 
on  the  possible  relation  of  insects  to  the  spread  of  poliomyelitis.  Some  of 
these  may  be  conveniently  discussed  separately. 

The  Grouping  of  Cases  in  City  Blocks — 

The  completed  block  in  a  city  forms  a  more  or  less  definite  entity,  which 
differs  in  many  respects  from  a  mere  aggregation  of  dwellings.  It  is  com- 
pletely walled  in  on  its  four  external  sides  and  usually  encloses  a  large  com- 
mon space  which  is  divided  into  yards  apportioned  to  the  dwellings.  Over 
quite  a  considerable  part  of  the  areas  of  Manhattan,  Brooklyn  and  The 
Bronx  where  poliomyelitis  has  been  prevalent,  the  dwellings  form  entirely, 
or  almost  entirely,  completed  blocks  of  this  kind. 

When  districts  of  this  kind  are  plotted  for  poliomyelitis,  it  is  seen  that 
the  distribution  of  cases  is  by  no  means  regular ;  such  could  hardly  be  ex- 
pected with  so  few  cases  occurring  over  a  small  area.  There  is  shown,  how- 
ever, quite  a  distinct  tendency  for  the  cases  to  group  themselves  more  or 
less  definitely  in  certain  blocks  while  others  of  similar  construction,  and 
supporting  a  similar  population,  remain  entirely  free  from  the  disease.  This 
tendency  is  well  illustrated  by  several  maps  (pp.  165-169)  taken  from  a  dis- 
trict on  the  middle  west  side  of  Manhattan  where  there  have  been  a  number 
of  small  foci  of  the  disease.  In  the  first  map  (A),  two  adjacent  city  blocks 
are  seen  to  be  heavily  infected,  having  seven  and  eleven  cases  respectively, 


149 

divided  between  two  sides  of  each  block,  while  the  contiguous  ones  have 
entirely  escaped  as  indicated.  In  another  group  (B),  one  block  has  suffered 
seven  cases,  while  in  the  adjacent  blocks  only  a  single  one  appears  acro'ss 
the  street  from  the  group  of  seven.  In  the  third  group  (C),  one  block  con- 
tains five  cases,  occurring  on  both  sides  of  the  block,  while  the  adjacent 
ones  are  free  from  the  disease.  In  this  same  small  area,  three  cases  appear 
along  the  northern  side  of  the  lowest  block,  but  none  across  the  street.  In 
the  fourth  group  one  block  contains  six  cases,  distributed  along  one  side, 
while  the  adjacent  one  has  three,  only  one  of  which  apparently  bears  any 
relation  to  those  across  the  street. 

It  is  not  easy  to  put  such  data  upon  a  statistical  basis,  but  so  many 
groupings  like  those  figured  have  occurred  that  it  does  not  seem  possible 
to  ascribe  them  to  chance.  It  is  very  evident  that  they  do  not  correspond 
with  the  more  common  movements  of  children  which  would  bring  them 
into  contact  with  other  children.  Such  association  in  playing  is  more  apt 
to  happen  between  neighbors  across  the  street  than  it  is  with  those  living 
down  the  block,  around  the  comer  or  on  the  next  street  (of  Fig.  1-A).  It 
is  also  not  easy  to  believe  that  any  human  carrier  or  any  flying  insects  would 
show  the  type  of  movement  or  migration  necessary  to  produce  case  distri- 
bution of  this  kind.  It  is,  however,  easier  to  believe  that  rats,  or  even  domes- 
tic cats  might  easily  migrate  in  this  fashion  by  the  way  of  yards  or  back 
fences.  It  may  be  mentioned  here  that  dogs  are  not  generally  present  in  the 
tenement  house  districts. 

These  maps  bring  out  another  interesting  fact.  It  will  be  seen  that  in 
the  few  blocks  represented,  five  houses  have  had  more  than  one  case  (4 
houses  with  2  and  one  with  3).  Multiple  cases  almost  invariably  o'ccur  in 
blocks  with  other  cases ;  that  is  to  say,  it  is  very  unusual  to  find  two  cases  in 
a  single  house  or  family  without  additional  cases  somewhere  else  in  the 
block. 

We  thus  see  that  there  is  a  tendency  for  certain  blocks  to  become 
centres  of  infection,  and  that  the  chances  of  second  cases  appearing  in 
families  is  enhanced  by,  and  seems  almost  dependent  upon,  the  presence  of 
other  cases  in  the  block.  This,  coupled  with  the  entire  absence  of  the  dis- 
ease in  so  many  blocks  adjacent  to  infected  ones  is  hard  to  understand  on 
the  basis  of  a  healthy  human  carrier  or  of  flying  insects. 

Since  a  large  part  of  the  cases  of  poliomyelitis  have  occurred  in  blocks 
that  are  used  exclusively  for  dwellings,  it  has  been  possible  to  observe  what 
relation  stores,  stables,  etc.,  may  bear  to  individual  cases.  This  cannot  be 
satisfactorily  tabulated  on  account  of  the  almost  innumerable  degree  of  asso- 
ciation with  one  type  or  another  of  food-shop,  market,  delicatessen,  restau- 
rant, bakery,  stable,  etc.,  and  we  have  had  to  rely  on  impressions  gained 
during  the  examinations  of  districts,  supplemented  by  notes  made  concerning 


Case 

1. 

Case 

2. 

Case 

3. 

Case 

4. 

Case 

5. 

Case 

6. 

Case 

7. 

Case 

8. 

Case 

9. 

Case 

10. 

Case 

11. 

150 

individual  cases.    The  following  list  is  typical  of  one  of  the  somewhat  better 
districts  where  there  has  been  a  group  of  scattered  cases  in  The  Bronx. 

Poultry  and  meat  market  in  building  (Tenement).* 

Candy  stare  next  door  (Tenement). 

Poultry  and  meat  market  in  building  (Tenement). 

No  shops  or  stables  {1}^  story  old  wooden  building). 

No  shops  or  stables  (Tenement). 

Stable  next  door  (2  story  old  wooden  house). 

No  shops  or  stable  (old  3  story  brick  house). 

Grocery,  candy  store,  laundry  in  building  (Tenement). 

No  shops  or  stable  (Tenement). 

Bakery  and  lunch  room  next  door    (old    3    story    wooden 

house). 
Grocery  and  dairy  in  building,  candy  and  ice  cream  store 
next  door  (Tenement). 
Case  12.     Bakery  next  door  (Tenement). 
A  second  area  in  Manhattan  was  as  follows : 
Case     1.     No  shops  or  stable  (Tenement). 

Over  delicatessen  shop,  stable  2  doors  away  (Tenement). 
Over  stable  (brick  house). 

Over  ice  cream  store,  macaroni  factory  next  door   (Tene- 
ment). 
Delicatessen  store  next  door  (Tenement). 
Over  junk  shop,  grocery  next  door  (Tenement). 
Grocery  on  one  side,  saloon  on  other,  with  meat  market  next 
(Tenement). 
Case     8.     Over  vacant  basement  grocery,  basement  grocery  next  door 

(Tenement). 
Case     9.     Vegetable  store  in  one  half  of  basement,  grocery  in  other 
(Tenement). 
No  shops  or  stable  (Tenement). 
No  shops  (Tenement). 

Over  meat  market,  adjoining  buildings  not  dwellings  (Tene- 
ment) . 
Over  meat  and  provision  store,  "  Pork "  store  next  door 

(Tenement). 
No  shops  nearer  than  market  two  doors  away  (Tenement). 
Over  undertaker's  shop  (Tenement). 
No  shops  or  stable  (Tenement). 
No  shops  or  stable  (Tenement). 
Grocery  next  door  (Tenement). 

*  The  word  tenement  is  used  only  for  large  buildings  of  four  to  six  stories,  each 
housing  numerous  families. 


Case 
Case 
Case 

2. 
3. 
4. 

Case 
Case 
Case 

5. 
6. 
7. 

Case 

10. 

Case 

11. 

Case 

12. 

Case 

13. 

Case 

14. 

Case 

15. 

Case 

16. 

Case 

17. 

Case 

18. 

151 

There  seems  to  be  a  well  marked  tendency  for  cases  in  Manhattan  to 
appear  in  the  immediate  vicinity  of  stables,  groceries,  meat  or  poultn,'  mar- 
kets, lunch  rooms,  delicatessen  shops  and  bakeries  or  macaroni  factories. 
The  kind  of  stores  vary,  of  course,  with  the  neighborhood,  and  some  of  the 
sorts  mentioned  do  not  occur  in  every  district.  However,  it  is  surprising 
with  what  regularity  one  or  the  other  is  found  in  the  building  or  next  door 
to  a  house  in  which  poliomyelitis  has  occurred.  Others  who  have  also 
examined  the  same  districts  with  an  unbiased  mind,  seem  always  to  believe 
that  cases  range  themselves  with  a  definite  relation  to  shops  of  this  type. 
It  has  been  repeatedly  pointed  out  in  earlier  epidemics  that  stables  are  often 
associated  with  cases  of  poliomyelitis.  This  has  been  undoubtedly  true  in 
New  York  during  the  present  summer,  but  the  other  association  with  pro- 
vision shops  has  also  forced  itself  upon  our  attention. 

In  combination  with  other  observations,  the  present  ones  are  interest- 
ing. Association  with  stables  at  one  time  appeared  suggestive  in  connection 
with  the  fact  that  stable  flies  might  be  the  carrier  of  poliomyelitis.  Stables 
support  rats  as  well  as  stable  flies,  and  as  food  shops  support  the  former, 
but  not  the  latter,  this  is  another  bit  of  evidence  pointing  toward  the  rat,  or 
perhaps  the  domestic  cat,  as  these  animals  are  maintained  in  particularly 
great  abundance  in  shops  of  the  kind  under  consideration.  It  is  a  generally 
accepted  idea  that  the  presence  of  cats  serves  to  keep  buildings  free  from 
rats.  This  is  erroneous  as  has  been  abundantly  shown  by  various  observers 
who  have  found  rats  and  cats  commonly  occurring  together,  both  in  build- 
ings and  on  shipboard. 

In  more  or  less  close  connection  with  this  matter,  there  is  another  which 
is  brought  out  in  our  notes  taken  o'f  individual  houses.  In  the  table  given 
on  page  150  it  will  be  noted  that  several  cases  occurred  in  wooden  buildings. 
It  happens  in  this  district  that  these  buildings  scattered  among  blocks  of 
tenements  are  relics  of  a  period  before  the  neighborhood  was  engulfed  by 
the  City.  These  buildings  house  an  insignificant  number  of  persons  com- 
pared to  the  tenements,  yet  they  have  suffered  considerably  from  polio- 
myelitis. This  is  only  an  isolated  example,  but  is  typical  of  the  fact  that  so 
far  as  one  can  form  an  opinion  by  careful  observation  and  reflection,  it  is 
the  older  or  more  poorly  cared  for,  particularly  wooden  houses  without 
cemented  basements,  which  suffer  most  severely.  Thus,  the  house  next 
door,  is  so  frequently  found  to  be  at  lea^t  noticeably  better  than  the  infected 
one,  either  newer,  of  better  construction,  kept  in  a  more  cleanly  condition, 
or  in  better  general  repair.  There  are,  of  cotirse,  exceptions,  many  due  as 
nearly  as  one  can  tell  to  the  association  with  shops  mentioned  above.  In 
certain  parts  of  Brooklyn,  where  houses  of  different  ages  and  types  of  con- 
struction are  grouped  together,  examples  of  this  kind  have  been  especially 
striking,  but  it  must  be  repeated  that  exceptions  are  by  no  means  uncommon. 

The  Grouping  of  Cases  in  Individual  Houses — 

In  going  over  areas  where  poliomyelitis  has  occurred  in  the  City,  one 
gains  the  impression    that    there    is    a    tendency  for  the  cases  to  be  more 


152 

abundant  on  the  lower  floors  of  buildings.  It  has  been  possible  to  examine 
this  matter  statistically,  and  also  to  compare  the  distribution  of  poliomyelitis 
with  scarlet  fever  and  diphtheria  in  this  respect.  For  this  purpose,  the 
Borough  of  Manhattan  was  selected  since  only  a  negligible  percentage  of 
the  buildings  used  as  dwellings  are  less  than  four  stories  in  height.  The 
vast  majority  of  the  population  is  housed  in  buildings  of  four  and  five  stories, 
so  that  the  number  of  cases  occurring  on  the  various  floors,  should  show 
whether  the  incidence  of  the  disease  really  bears  a  relation  to  the  floor  upon 
which  the  families  live. 

For  a  check,  two  diseases,  scarlet  fever  and  diphtheria,  known  to 
be  spread  by  personal  contact  and  to  some  extent  by  apparently  healthy  car- 
riers were  chosen.  The  way  in  which  these  latter  two  diseases  are  appor- 
tioned to  the  various  floors  of  dwellings  in  Manhattan  during  the  late  Spring 
and  early  Summer  of  1916,  and  the  distribution  of  poliomyelitis  during  the 
epidemic,  is  shown  on  the  accompanying  charts  (pages  171  and  173). 

These  data  are  somewhat  difficult  to  interpret  as  in  a  number  of  cases 
the  floor  is  given  as  "  top  "  instead  of  by  number.  Some  facts  are,  however, 
clearly  evident.  On  the  first  floor,  there  are  fewer  cases  than  on  the  second 
and  third  floors,  as  quite  frequently  there  are  stares  or  places  of  business 
on  this  floor,  which  reduce  the  number  of  available  dwelling  places.  It  is 
seen  that  17.9  per  cent,  of  the  cases  of  poliomyelitis  were  on  the  first  floor, 
against  12.9  and  11.8  for  diphtheria  and  scarlet  fever  respectively.  On  the 
basement,  first,  and  second  flo'ors  together,  the  number  of  cases  of  polio- 
myelitis has  been  greater  and  on  the  third  and  higher  floors  together  it  has 
been  lower,  than  in  the  case  of  either  diphtheria  or  scarlet  fever,  as  is  shown 
in  the  following  table  taken  from  the  chart.  A  very  few  cases  on  higher 
floors  and  in  private  ho'uses  are  omitted;  they  amount  to  only  1^  of  the 
entire  totals. 

Basement,    lit  and   2nd  Floors.  Third  and  Higher  Floors. 

Poliomyelitis    44.3%  Poliomyelitis    54.1% 

Diphtheria    39.9%  Diphtheria    58.9% 

Scarlet  Fever  37.0%  Scarlet  Fever  60.5% 

In  Brooklyn  there  appears  to  have  been  an  even  greater  tendency  for 
the  cases  of  poliomyelitis  to  be  more  abundant  on  the  lower  floors  of  dwell- 
ings (page  175).  Here,  however,  on  account  of  the  number  of  buildings  of 
only  two  stories,  it  is  impossible  to  make  a  dogmatic  statement. 

It  can  be  seen  that  poliomyelitis  has  been  consistently  more  abundant 
on  the  first  two  floors,  and  less  abundant  on  the  higher  ones.  This  difiference 
implies  an  infective  agent  which  is  more  prevalent  near  the  ground ;  the 
only  other  plausible  assumption  would  seem  to  be  that  the  disease  is  favored 
more  by  the  lack  of  air  and  light  on  lower  floors  than  are  scarlet  fever  and 
diphtheria.  This  greater  prevalence  on  lower  floors  is  also  easily  explained 
by  an  insect  carrier  such  as  various  flies  and  mosquitoes,  or  by  an  associa- 
tion with  rats  or  cats.  In  the  case  of  the  rat  it  would  seem  that  the  dififer- 
ence should  be  more  marked.    This,  however,  is  only  an  opinion,  not  based 


153 

on  actual  facts.  Rats  do  commonly  occur  on  the  upper  floors  of  buildings, 
but  presumably  in  lesser  abundance  than  on  the  lower  ones.  In  this  con- 
nection it  is  noticeable  than  in  children  under  one  year  old,  at  which  age 
it  is  probable  that  they  play  more  regularly  in  the  apartment  in  which  they 
live,  the  divergence  between  cases  occurring  on  lower  floors  and  upper  ones 
is  greater  than  in  older  children,  who,  it  may  be  expected,  spend  more  of 
their  time  down  stairs  or  on  the  street.  The  following  table  illustrates  this 
point : 

Age  Under  1  Yr.  Age  Over  5  Yrs. 

Basement,  1st  and  2d  Floors 49 . 3  44 . 8 

Third  Floor  and  above 50.6  55.2 

Number  of   Cases 227  301 

In  over  500  cases  about  which  data  is  available,  there  is  a  difference  of 
5%  in  the  number  of  cases  occurring  in  the  lower  and  upper  division  of 
buildings,  when  we  compare  very  young  children  and  those  of  considerable 
age.  This  is  additional  evidence  that  there  is  actually  a  selection  of  lower 
floors  and  that  this  selection  is  due  to  the  failure  of  the  infective  agent  to 
attain  the  equal  prevalence  on  higher  floors.* 

Houses  in  Which  More  Than  One  Case  Has  Developed — 

Some  very  interesting  data  which  bear  upon  the  possibility  of  insect 
transmission  are  brought  out  by  an  examination  of  the  distribution  and 
sequence  of  the  cases  in  houses  and  in  families  where  more  than  a  single 
case  has  occurred.  The  number  of  such  instances  is  smaller  than  happens 
with  mast  of  the  acute  infectious  diseases  of  childhood.  This  fact  mav  be 
satisfactorily  explained  in  several  ways,  and  in  itself  furnishes  no  evidence 
of  value.  The  greatest  number  of  additional  cases  which  occurred  in  families 
have  had  an  onset  coincident  with  that  of  the  first,  and  the  number  of  addi- 
tional cases  has  decreased  almost  uniformly  from  day  to  day  until  after  a 
fortnight  a  second  case  almost  never  appeared.  This  may  have  been  due 
to  the  quarantine  measures  adopted,  which  have  usually  included  the  removal 
of  the  patient  to  a  hospital.  In  fact  the  same  behavior  is  shown  by  scarlet 
fever,  which,  together  with  poliomyelitis  is  graphically  represented  on  the 
accompanying  chart  (Fig.  5).  That  this  may  not  be  true,  however,  is  sug- 
gested by  the  fact  that  the  appearance  of  the  later  cases  in  the  same  house, 
but  not  in  the  same  family  does  not  follo^v  the  same  curve,  but  that  with 
the  exception  of  a  single  drop  on  the  third  day,  it  has  dropped  much  more 
gradually.  Another  noteworthy  fact  is  that  the  number  of  cases  appearing 
in  the  same  building,  but  in  another  family  or  apartment,  is  far  greater  in 
this  epidemic  of  poliomyelitis  than  has  occurred  in  1916  with  either  scarlet 
fever  or  diphtheria.  The  latter  disease  has  not  been  included  on  the  chart, 
but  the  following  table  shows  the  apportionment  of  later  cases  by  houses  and 
families  for  the  three  diseases. 

*  This  study  is  incomplete  and  the  conclusion  therefore  not  fully  justified  owing 
to  the  fact  that  no  count  was  made  of  the  children  of  the  specially  susceptible  ages,  or 
the  children  of  all  ages  living  in  apartments  on  the  various  floors  of  the  tenements. 
It  cannot  be  safely  assumed  that  there  is  an  equal  distribution  of  children  of  all  age 
groups  on  the  different  floors  of  the  tenements  in  New  York  City. —  [Editor's  Note.] 


154 

Cases  in 
Cases  in  Same  Howse  But 

Same  Family,      In  Different  Family. 

Poliomyelitis     335  or  56%  257  or  43% 

Scarlet   Fever    198  or  86%  31  or  13% 

Diphtheria    73  or  78%  20  or  21% 

It  is  evident  that  there  is  a  very  great  difference  between  poliomyelitis 
and  the  other  two  diseases  in  the  number  of  later  cases  that  have  appeared 
in  the  same  building,  but  in  a  different  family.  Thus  43^  of  the  additional 
cases  or  early  half  appeared  in  the  same  house,  but  outside  the  family  in 
which  the  original  case  occurred.  This  is  more  than  double  the  number 
(21%)  for  diphtheria  and  more  than  treble  (13%)  the  number  for  scarlet 
fever.  It  seems  incredible  that  such  a  divergence  should  exist  if  poliomyeli- 
tis like  the  others  were  spread  through  infection  from  sick  individuals 
or  healthy  carriers,  and  the  susceptibility  of  the  exposed  individuals  is  the 
same. 

The  gradual  dropping  off  of  additional  cases  from  day  to'  day  and  the 
large  proportion  of  cases  occurring  in  other  families  in  the  house  may  be 
easily  explained  on  the  basis  of  the  appearance  of  some  non-human  popu- 
lation in  the  house,  not  definitely  restricted  by  the  boundaries  which  prevent 
intimate  association,  followed  by  its  actual  disappearance  or  inability  to 
cause  infection  after  a  variable  length  of  time.  So  far  as  this  evidence  is 
concerned,  this  population  might  be  composed  either  of  insects  or  of  higher 
animals  such  as  rodents  or  cats. 

Insects  as  Possible  Carriers  of  Poliomyelitis — 

As  has  been  pointed  out  on  the  preceding  pages,  many  facts  in  the  epi- 
demiology of  poliomyelitis  seem  to  show  the  spread  of  the  disease  to  be 
such  that  it  is  impossible  to  understand  its  distribution  without  assuming 
either  a  migrating,  i.e.,  healthy  human  carrier,  or  a  migrating  non-human 
carrier,  either  an  insect  or  another  animal,  perhaps  both. 

Aside  from  possible  spread  through  numerous  healthy  adult  human 
carriers  no  carefully  considered  hypothesis  has  been  advanced  which  does 
not  include  some  insect  in  the  role  of  a  casual  or  specific  carrier. 

There  is  much  experimental  evidence  in  support  of  the  idea  of  contact. 
Thus,  it  has  been  shown  that  the  virus  of  poliomyelitis  can  be  recovered 
from  the  mouth,  nose  and  intestines  in  sufficient  quantity  and  in  such  con- 
ditions that  it  is  capable  of  causing  the  infection  of  monkeys  iipon  intra- 
cerebral" inoculation.  This  recovery  of  the  virus  has  actually  been  made, 
from  apparently  healthy  persons  who  have  been  in  contact  with  children  ill 
with  poliomyelitis.  After  this  virus  has  multiplied  in  the  central  nervous 
system  of  the  monkey  thus  infected^  it  is  capable  of  infecting  another  monkey 
when  implanted  upon  the  mucous  membrane  of  the  nose.  This  of  course 
suggects  that  human  cases  may  result  from  infective  nasal  or  buccal  dis- 
charges, not  gaining  access  to  the  brain  directly,  but  through  the  nasal 
mucosa.     While  suggestive,  this  evidence  is  not  conclusive  for  it  is  quite 


155 

probable  that  the  same  procedure  could  be  followed  with  the  virus  of  rabies 
secured  from  a  person  afflicted  with  the  disease.  Other  experimental  ob- 
ser^-ations  upon  monkeys  have  shown  that  the  quantity  of  poliomyelitis  virus 
present  in  the  blood  during  early  stages  of  the  disease  is  very  minute,  and 
that  considerable  quantities  of  blood  are  required  to  reproduce  the  disease 
in  another  monkey.  This  would  suggest  that  infection  was  not  secured  from 
the  blood,  or  that  if  it  were,  an  insect  acting  as  a  biological  carrier  and  not 
as  a  mechanical  one  should  be  involved.  That  the  virus  is  not  more  abundant 
in  the  blood  of  human  cases  in  the  early  stages  of  the  disease  than  it  is  in 
monkeys  would  seem  probable,  although  by  no  means  proved,  since  the  ex- 
perimental transfer  from  one  animal  to  another  is  accomplished  by  use  of 
portions  of  the  infected  spinal  cord,  and  departs  so  widely  from  what  must 
normally  occur  that  it  is  possible  that  stages  of  invasion  in  which  the  blood 
stream  plays  a  part  may  be  entirely  eliminated  by  the  present  laboratory 
methods. 

It  is  quite  possible  that  the  virus  might  be  obtained  by  a  blood-sucking 
insect  from  the  superficial  nerves,  some  of  which  are  commonly  reached  by 
the  mouth  parts  at  the  time  of  the  biting.  Similarly,  inoculation  into  these 
ner^-es  could  easily  occur  at  the  time  of  a  later  feeding  by  the  insect. 

As  already  mentioned,  the  evidence  that  insects  are  a  factor  in  the 
spread  of  poliomyelitis  is  based  to  a  great  extent  upon  epidemiological  evi-. 
dence.  Aside  from  facts  of  general  application  referred  to  in  the  introduc- 
tory part  of  the  report,  the  present  epidemic  has  offered  an  opportunity  to 
examine  the  spread  of  the  disease  in  a  totally  different  environment  from 
those  in  which  it  has  previously  been  studied.  Such  facts  and  observations 
have  already  been  given  as  seem  to  bear  on  insects,  but  attention  has  been 
called  to  only  a  few  ways  in  which  they  may  be  applied  to  the  purpose  of 
the  present  investigation.  No  attempt  has  been  made  to  conduct  an  actual 
census  of  the  insects  present  in  houses  or  apartments  where  poliomyelitis 
has  occurred,  as  it  did  not  seem  that  such  a  procedure  would  lead  to  satis- 
factory results.  It  is  apparent  that  a  disease  so  common  as  poliomyelitis, 
if  dependent  upon  an  insect,  must  depend  upon  some  abundant  species.  That 
any  insect  occurring  in  sufficient  abundance  to  account  for  cases  over  large 
areas  should  be  absent  in  others  does  not  seem  probable,  and  is  not  in  agree- 
ment with  what  is  known  to  occur  in  the  case  of  other  insect-borne  diseases. 
With  yellow-fever,  for  example,  the  yellow-fever  mosquito  (aedes)  regu- 
larly occurs  over  large  areas  {e.g.,  the  southern  United  States)  where 
the  disease  does  not  exist,  and  it  is  also  regularly  distributed  in  all  parts  of 
a  city  {e.g.,  Guayaquil,  Ecuador),  while  the  cases  of  yellow-fever  occur  in 
such  a  way  that  the  comparative  abundance  of  mosquitoes  does  not  show  a 
definite  correlation  with  the  number  of  infected  ones.  Such  is  also  the  case 
with  bubonic  plague,  although  here  the  greater  abundance  of  the  disease  in 
parts  of  a  city  heavily  infested  wnth  rats  is  evident  when  a  number  of  areas 
are  examined  for  rat  prevalence.  For  this  reason  no  census  of  houses  has 
been  taken  in  studying  the  present  outbreak  of  poliomyelitis,  but  many  cir- 


156 

cumscribed  areas  have  been  examined  for  the  general  type  of  insect  fauna 
existing  there. 

There  are  three  types  o'f  insects  which  are  suited  by  their  habits  and 
association  with  man  to  act  as  carriers  of  human  infectious  diseases.  One 
.type  includes  such  insects  as  lice  and  bedbugs.  The  first  are  epizoic  para- 
sites during  their  entire  life  and  do  not  commonly  pass  from  one  individual 
to  another  except  during  close  personal  contact.  They  do  not  remain  alive 
for  any  length  of  time  away  from  their  host.  Such  insects  obviously  cannot 
account  for  the  spread  of  poliomyelitis  since  cases  continually  come  to  notice 
where  a  transfer  of  lice  could  not  have  occurred.  In  fact  this  commonly  is 
more  difficult  than  the  transfer  of  infection  by  droplet  contagion.  A  louse- 
borne  disease  like  typhus  fever  also  shows  an  entirely  different  epidemiology 
from  poliomyelitis.  The  bedbug  is  less  dependent  upon  its  host  as  it  can 
live  for  long  periods  without  f oo'd  and  may  thus  easily  change  its  host.  How- 
ever, it  does  not  commonly  migrate  on  its  host,  nor  probably  to  any  extent 
through  tenement  buildings  except  when  impelled  by  the  continued  vacancy 
of  apartments.  It  lives  almost  entirely  on  human  blood  and  thus  does  not 
migrate  on  the  bodies  of  animals.  Extensive  migration  of  such  kinds  as 
would  be  necessary  if  it  were  an  active  agent  in  the  spread  of  poliomyelitis, 
even  under  conditions  existing  in  the  crowded  sections  of  New  York  seem 
utterly  improbable.  In  this  connection  it  must  be  mentioned  that  the  virus 
has  actually  been  recovered  from  bedbugs  that  have  fed  on  the  experiment- 
ally inoculated  monkeys. 

Another  type  of  blood-sucking  insects  which  remain  quite  closely  asso- 
ciated with  their  host  are  various  species  of  fleas.  These  insects,  like  the 
bedbug,  never  develop  wings  and  consequently  do  not  migrate  extensively 
through  their  own  activities.  They  can  live  away  from  the  body  of  their 
host  for  a  shorter  length  of  time  than  the  bedbug,  but  so  far  as  is  known,  the 
time  during  which  they  can  remain  alive  depends  to  a  great  extent  upon 
the  amount  of  moisture  present  in  the  air  or  in  such  loose  dirt,  rubbish,  etc., 
as  may  afford  them  a  hiding  place.  They  undergo  their  developmental 
stages  (egg,  larva  and  pupa)  either  in  the  nests  of  rodents,  cats,  or  dogs 
in  the  case  of  our  common  household  species,  or  in  accumulations  of  dust 
and  fine  dirt  which  may  accumulate  in  the  corners  or  cracks  of  floors  in 
dwellings.  Those  species  which  occur  on  the  cat,  dog  or  on  rats  and  mice 
are  capable  of  considerable  migration,  since  they  usually  remain  on  the  host 
animal  continuously  after  they  have  reached  the  adult  stage,  and  thus  go 
with  it  wherever  it  may  wander. 

Until  recently  it  was  not  believed  by  us  that  fleas  agreed  on  any  essen- 
tials of  prevalence  or  possibilities  of  migration  with  what  would  be  required 
of  a  carrier  of  poliomyelitis.  Like  many  insects  they  were  long  ago  sug- 
gested as  possible  vectors.  Conn  once  regarded  them  as  perhaps  associated 
with  the  spread  of  poliomyelitis,  but  before  enough  was  known  epidemio- 
logically  to  examine  them  critically.  Since  Richardson  advanced  this  idea 
that  the  disease  showed  an  apparent  relation  to  rats  in  Massachusetts  the 


157 

flea  question  has  received  more  attention.  As  the  seasonal  prevalence  of 
fleas  seems  incompatible  with  that  of  poliomyelitis,  it  was  suggested  that 
data  be  secured  on  the  relative  abundance  of  fleas  on  cats  during  different 
parts  of  the  year.  FYom  an  examination  of  cats  collected  by  the  Boston 
Animal  Rescue  League  during  1913-1914  it  was  ascertained  that  the  sea- 
sonal abundance  of  fleas  on  cats  corresponds  quite  closely  to  that  of  polio- 
myelitis, in  fact  more  closely  than  that  of  the  stable-fiy  at  least  during  the 
winter.  During  the  winter,  fleas  become  scarce,  especially  in  late  winter  and 
spring,  attaining  their  minimum  in  this  case  during  March,  after  which  they 
rapidly  increased  until  July  at  which  time  the  observations  had  to  be  dis- 
continued. 

The  persistence  of  fleas  in  smaller  numbers  during  the  winter  is  quite 
in  harmony  wnth  the  frequent  continuance  of  poliomyelitis  into  late  fall,  and 
their  rapidly  increasing  abundance  during  midsummer  also  coincides  with 
the  rise  of  the  disease. 

If  we  now  compare  poliomyelitis  with  a  disease  known  to  be  spread 
almost  exclusively  by  fleas  and  rats  we  find  a  number  of  striking  similari- 
ties, but  also  some  very  evident  differences.  A  somewhat  hasty  examination 
of  the  literature  relating  to  the  epidemiology  of  bubonic  plague  made  by 
Dr.  Freeman  and  the  writer,  tended  strongly  to  confirm  our  belief  that  there 
are  many  similarities  between  these  two  diseases  in  the  development  of  epi- 
demic foci  and  the  relation  of  the  latter  to  scattered  and  more  or  less  iso- 
lated cases.  During  recent  times  there  have  been  no  very  extensive  out- 
breaks of  bubonic  plague  in  temperate  regions  where  the  climate  corresponds 
at  all  closely  to  that  o'f  the  northern  countries  in  which  poliomyelitis  has 
been  closely  studied.  The  progressive  development  of  a  number  of  small 
epidemics  of  plague  that  have  been  very  carefully  followed  show  a  close 
simlarity  to  epidemics  of  poliomyelitis  in  their  main  features  of  distribution. 
This  is  especially  true  of  the  first  general  scattering  o'f  cases,  the  beginning 
of  small  foci  and  the  way  in  which  an  epidemic  spreads  into  new  territory 
while  the  original  small  foci  may  gradually  enlarge.  As  has  been  shown  on 
previous  pages,  many  features  of  the  distribution  and  spread  of  poliomyelitis 
during  the  present  epidemic  lend  themselves  readily  to  interpretation  on 
the  basis  of  rats.  These,  as  enumerated  and  considered  in  detail  are,  the 
grouping  of  the  denser  foci  along  the  various  water  fronts  of  the  city,  their 
development  in  many  localities  without  definite  relation  to  the  distribution 
and  density  of  the  human  population,  the  spread  of  the  epidemic  in  such  a 
way  as  rats  might  be  expected  to  migrate,  the  grouping  of  cases  in  neigh- 
borhoods and  in  houses,  etc. 

The  way  in  which  the  small  groups  of  cases  have  appeared  in  certain 
city  blocks  and  the  marked  tendency  of  additional  cases  in  the  same  house 
to  appear  outside  of  the  family  or  apartment  are  also  more  easily  explained 
on  this  basis  than  upon  that  of  personal  contact.  The  greater  incidence  of 
poliomyelitis  on  the  lower  floors  of  the  tenements  and  apartments  is  also 
plausibly  explained  in  the  same  way. 


158 

The  attempt  has  been  made  to  ascertain  whether  rats  or  evidence  of 
their  presence  could  be  found  generally  in  houses  where  cases  of  polio- 
myelitis have  occurred.  In  a  great  number  of  instances  their  presence  has 
been  satisfactorily  shown  by  direct  evidence  such  as  runways  or  rat-holes. 
In  others  the  information  has  been  obtained  by  questioning  residents  of  the 
buildings.  The  last  mentioned  is  very  unsatisfactory;  in  some  cases  there 
has  been  evident  exaggeration,  and  in  many  others  an  equally  evident  desire 
to  deny  the  presence  of  anything  not  considered  proper,  or  anything  lor 
which  repressive  measures  might  be  required  by  the  Department  of  Health. 
In  others  the  proximity  of  stables,  bake-shops,  meat  and  poultry  stores,  etc., 
has  given  strong  presumptive  evidence  of  rats  in  at  least  small  numbers. 
Not  many  trapping  experiments  have  been  tried,  but  where  attempts  have 
been  made  to  obtain  them  from  apparently  suitable  houses  where  polio'- 
myelitis  has  occurred,  they  have  been  successful.  These  rats  as  was  to  have 
been  expected  have  been  found  to  harbor  fleas. 

The  great  ease  and  rapidity  with  which  rats  may  migrate  in  both  city, 
suburbs  and  country  have  been  shown  by  the  spread  of  bubonic  plague,  and 
under  urban  conditions  at  least,  by  actual  observations  cm  market  rats.  Just 
what  opportunities  for  migration  and  to  what  extent  rats  might  avail  them- 
selves of  these  opportunities  in  a  city  like  New  York  is  a  question  rather 
difficult  of  definite  answer  without  considerable  investigation.  The  occur- 
rence of  rats  on  shipboard  is  notorious  and  there  is  plenty  of  opportunity 
for  these  animals  to  travel  along  the  water-front  following  the  movements 
of  boats.  No  experiments  have  been  actually  carried  on  in  the  city,  but 
there  can  be  no  reason  to  doubt  that  such  travel  actually  occurs.  As  men- 
tioned on  a  previous  page  one  small  focus  in  lower  Manhattan  is  closely 
associated  with  a  second  focus  adjacent  to  another  landing  of  a  certain  line 
of  steamers.  The  apparent  spread  of  poliomyelitis  has  often  been  seen  to 
follow  along  water  routes,  an  occurrence  usually  attributed  to  the  move- 
ments of  human  freight.  However,  the  fact  that  some  of  the  most  noticeable 
early  foci  in  New  York  State  this  summer  were  about  towns  regularly  visited 
by  steamers  from  New  York  City  is  at  least  worthy  of  mention.  More 
people  travel  by  rail  from  New  York  City  than  by  water  and  they  reach 
their  destinations  more  quickly.  Nevertheless  the  water  route  has  been  the 
most  rapid  for  the  disease  in  this  case,  and  the  same  association  with  ports 
has  been  noted  before  on  occasions  not  within  the  scope  of  this  report. 
Another  method  of  travel  open  tO'  rats  is  transportation  in  freight  cars, 
either  free  or  inadvertently  imprisoned  in  packing  cases.  Plague  follows 
the  same  course,  and  has  in  some  cases  been  found  to  follow  railroad  routes. 

In  cities  the  larger  sewers  support  a  considerable  rat  fauna,  depending 
upon  the  construction,  size  and  condition  of  repair  of  the  sewers.  The  older 
portions  of  the  city  are  supplied  to  a  great  extent  with  systems  of  bricked- 
in  sewers  which  commonly  harbor  rats,  while  many  pipe  sewers,  particu- 
larly in  the  newer  districts,  offer  but  small  opportunities  for  rats  to  escape. 
Another  way  in  which  they  may  gain  access  to  houses  is  through  large 


159 

basement  drains  which  open  directly  into  the  sewers  without  any  water- 
trap.  Whether  certain  streets  which  have  been  immune  during  the  epidemic 
{e.g.,  E.  116th  Street)  are  supplied  with  sewers  different  from  tho'se  on  the 
adjoining  streets,  has  not  been  ascertained. 

It  thus  appears  that  rats  and  fleas  show  a  number  of  striking  peculiari- 
ties in  distribution  and  behavior  which  are  very  suspicious  when  compared 
with  the  observed  epidemiology  of  poliomj-elitis. 

From  the  standpoint  of  experimental  evidence  there  is  no  positive  sup- 
port for  the  contention  that  the  two  are  associated.  No  published  reference 
to  paralyzed  rats  has  been  made,  but  we  have  every  reason  to  suppose  that 
these  animals  are  subject  to  paralytic  diseases  such  as  are  known  commonly 
to  occur  in  various  frequently  observed  domesticated  animals  like  cats, 
dogs,  horses,  cattle,  etc.  In  none  of  these  animals,  however,  has  it  been 
possible  to  show  that  such  paralyses  as  have  been  observed  are  identical  with 
poliomyelitis.  If  we  knew  that  no  animal  was  susceptible,  and  that  none 
could  act  as  a  reservoir  for  the  virus  the  situation  would  be  much  clearer.  To 
deny  that  animal  reservoirs  exist  is  taking  much  for  granted,  particularly 
as  it  is  very  probable  that  even  in  children  a  large  number  of  abortive  non- 
paralytic cases  occur.  That  such  cases  should  be  the  prevalent  type  in  some 
animal  acting  as  a  reservoir  is  at  least  perfectly  plausible,  and  we  should 
not  expect  to  find  the  virus  readily  recoverable  in  large  quantities  from  the 
unaffected  spinal  cord  of  non-paralytic  animals.  Since  the  spinal  cord  is 
the  portion  of  the  body  usually  taken  for  test,  animal  reservoirs  might  easily 
escape  attention  unless  searched  for  with  great  care. 

Before  leaving  the  discussion  of  fleas  it  should  be  noted  that  these  in- 
sects were  not  eliminated  in  the  experiments  referred  to  elsewhere,  where 
poliomyelitis  was  apparently  transmitted  successfully  from  monkey  to  mon- 
key by  the  bites  of  the  stable-fly. 

The  second  type  of  insects  suited  to  act  as  vectors  for  pathogenic  micro- 
organisms are  various  actively  flying  species  of  blood-sucking  habits.  The 
most  prevalent  forms  are  mosquitoes  and  a  number  of  allied  flies  belonging 
to  several  families,  gad-flies  belonging  to  the  family  Tabanidae,  and  the 
stable-fly  and  a  few  allies  belonging  to  the  family  Muscidae.  No  others 
have  a  sufficiently  wide  distribution  and  occur  regularly  in  all  of  the  regions 
and  localities  where  poliomyelitis  has  become  epidemic. 

The  status  of  the  stable-fly  has  been  already  mentioned  and  has  been 
dealt  with  in  detail  in  other  publications.  It  may  be  pointed  out  that  the 
epidemiological  evidence  which  so  strongly  incriminated  this  insect  in  studies 
of  epidemics  in  smaller  cities  and  in  towns  and  villages  does  not  apply  with 
the  same  force  under  conditions  existing  in  New  York  City.  Like  other 
flying  insects,  its  behavior  and  comparative  abundance  is  not  compatible 
with  the  observed  distribution  and  spread  of  the  disease  as  enumerated  else- 
where. Viewed  in  the  light  of  the  present  epidemic,  it  seems  equally  easy 
to  explain  at  least  most  of  the  previous  epidemics  on  the  basis  of  rat  and 


160 

flea  infection,  and  much  easier  to  understand  the  development  of  this  sum- 
mer's outbreak  in  New  York  City  on  the  same  basis. 

Mosquitoes  and  their  relatives  do  not  seem  to  offer  any  promising  lines 
of  investigation.  So  far  as  our  present  knowledge  goes  there  is  no  reason 
to  believe  that  any  of  them  could  account  for  the  conditions  existing  during 
the  New  York  epidemic.  They  vary  greatly  in  prevalence  in  different  parts 
of  the  city,  and  while  their  relative  abundance  agrees  more  or  less  with  the 
general  trend  of  the  epidemic,  it  is  difficult  to  understand  the  definite  foci 
which  have  developed,  and  gradually  enlarged  with  so  little  change  in  shape 
and  position.  Like  other  flying  insects,  the  movement  of  mosquitoes  in  the 
country  is  considerably  like  that  of  poliomyelitis,  but  not  so  in  the  city.  This 
statement  would  not  apply  to  a  truly  domestic  species,  like  the  yellow-fever 
mosquito  (Aedes),  but  this  species  and  the  Filaria  mosquito  (Culex- 
fasciatiis)  are  notable  exceptions.  The  common  rain-barrel  mosquito  (Culex- 
pipiens)  is  the  nearest  approach  to  this  habit  among  our  northern  species. 
It  is  not  generally  prevalent  in  a  city  like  New  York. 

Certain  conditions  existing  in  some  localities  where  Tabanid  flies  o'f  the 
genera  Tabanus  and  Chrysops  are  abundant  has  made  it  seem  possible  that 
these  insects  might  act  as  carriers  of  poliomyelitis.  The  larger  species  are 
most  abundant  along  the  ocean  beaches  where  these  adjoin  salt-marsh  areas, 
along  rivers,  streams  and  ponds,  or  about  stables,  dairies,  etc.,  where  large 
animals  are  housed.  The  smaller  species  (Chrysops)  occur  almost  ex- 
clusively in  wooded  areas  and  bite  man  commonly  about  the  head  and  ears 
in  all  of  our  country  districts.  Like  the  stable-fly  these  flies  feed  normally 
upon  the  blood  of  animals  of  various  kinds,  but  with  the  exception  of  the 
largest  species,  commonly  bite  human  beings  also.  An  extremely  annoying 
species  is  abundant  on  the  beaches  where  it  goes  by  the  name  of  "  green- 
head  "  on  account  of  its  large  brilliant  green  eyes.  It  is  a  very  persistent 
and  vicious  biter.  -These  flies  have  previously  not  been  free  from  suspicion 
as  possible  carriers  of  poliomyelitis  because  of  their  general  prevalence  in 
the  country  and  their  abundance  on  the  beaches  which  are  visited  so  regu- 
larly by  enormous  numbers  of  persons  with  children.  'It  is  very  easy  to 
find  that  children  have  recently  visited  a  beach  resort  and  to  be  led  to  think 
that  the  visit  is  related  to  infection  with  poliomyelitis.  The  numerous  small 
foci  described  on  an  earlier  page  preclude  the  possibility  that  poliomyelitis 
is  usually  contracted  so  far  away  from  home  as  at  the  beach,  and  the  lack 
of  outbreaks  of  greater  size  in  the  summer  beach  camps,  is  additional  evi- 
dence. However,  these  flies  frequently  occur  about  stables,  even  in  the 
centre  of  the  city,  where  they  have  evidently  flown  for  considerable  distance, 
since  the  species  breed  in  marshy  lands  about  streams,  ponds,  etc.  They 
are  attracted  only  to  living  animals,  however,  and  do  not  occur  about  markets 
or  food  shops.  Since  their  bite  is  severe,  it  is  usually  remembered,  but  only 
one  definite  history  of  a  bite  of  this  kind  can  be  recalled  after  visiting  many 
families  where  poliomyelitis  has  occurred  in  the  several  boroughs.  This 
does  not  include  beaches ;  there  they  are  by  no  means  uncommon. 


161 

The  house-fly  has  been  very  frequently  mentioned  as  a  possible  carrier 
of  the  poliomyelitis  virus.  Its  activities  have  been  supposed  to  be  accessory 
to  contact  infection  from  person  to  person  through  the  medium  of  the  nasal 
secretio'ns.  The  flies  could  of  course  also  secure  the  virus  from  fecal  dis- 
charges or  from  the  secretions  or  excreta  of  animals  if  it  exists  in  such  places. 
In  any  case  they  could  act  only  as  accessory  to  some  other  method  of  infection, 
occurring,  for  example,  through  the  nose  or  mouth,  since  flies  are  attracted 
to  the  mouths  and  noses  of  very  small  children  as  well  as  to  an  unprotected 
wound  or  surface  lesion  o'f  any  kind.  Food  might  of  course  become  infected 
in  the  same  way.  House-flies  may  thus  be  called  upon  to  explain  a  large 
percentage  of  cases  where  direct  contact  or  carrier  infection  cannot  be  shown 
to  have  occurred.  It  is  very  difficult  to  analyze  a  combination  of  po'ssibilities 
of  this  sort,  as  one  sees  by  recollecting  the  widely  variant  views  which  have 
been  held  till  recently  concerning  the  relative  importance  of  the  house-fly 
in  disseminating  the  typhoid  bacillus.  With  poliomyelitis  the  situation  is 
much  more  difficult  on  account  of  lack  of  knowledge,  of  many  of  the  im- 
portant factors  concerned.  It  appears,  however,  that  the  numerous  dif- 
ferences in  the  abundance  of  house-flies  in  certain  sections  of  the  city  ought 
to  be  definitely  reflected  in  the  incidence  of  poliomyelitis  if  this  insect  be  a 
factor.  This  is  not  the  case,  so  far  as  has  been  ascertained.  There  are  a 
number  of  streets  very  heavily  supplied  with  flies,  attracted  to  pushcarts 
full  of  vegetables  and  other  sorts  of  food,  in  certain  parts  of  the  lower  east 
side.  Adjacent  to  these  streets  are  others  where  there  is  no  special  attrac- 
tion for  flies.  There  has  been  no  excess  of  poliomyelitis  on  such  "  fly- 
streets."  Flies  cannot  readily  account  for  the  restriction  of  the  disease  to 
blocks  either,  since  flies  should  show  at  least  as  great  a  tendency  to  cross 
the  street  as  to  travel  along  a  block  or  to  cross  through  it  into  the  buildings 
on  the  near  side  of  the  next  street.  It  is  also  difficult  to  see  why  they  should 
not  cause  the  larger  foci,  which  involve  areas  including  a  number  of  adjacent 
blocks,  to  spread  more  diffusely  into  the  currounding  territory  than  has 
actually  been  seen  to  be  the  case.  At  any  rate  we  should  have  to  regard 
the  house-fly  as  only  a  contributing  factor,  additional  to  spread  by  contact. 
That  it  should  act  as  it  does  in  typhoid-fever  by  contaminating  food  is  an 
assumption  not  supported  by  any  evidence.  The  failure  of  certain  outbreaks 
to  disappear  with  the  house-fly  in  the  cool  months  speaks  against  it  as  a 
factory  also.  The  persistence  of  the  present  epidemic  in  Massachusetts  is 
a  case  in  point. 

The  only  other  Arthropods  suited  to  convey  infections  of  warm-blooded 
animals  are  the  ticks  and  their  allies.  So  far  these  insect-like  animals  have 
been  shown  to  carry  only  Spirochetae-Piroplasmata  and  similar  organisms. 
They  can  be  absolutely  eliminated  as  far  as  human  infection  of  poliomyelitis 
is  concerned. 

The  development  of  epidemic  foci  of  large  size  in  various  parts  of  the 
eastern  United  States  apparently  as  the  direct  result  of  introduction  of  the 


162 

infection  from  New  York  City  this  summer,  throws  new  light  upon  the 
pecuHar  restriction  of  poHomyeHtis  to  the  summer  months.  This  also 
supplements  and  confirms  observations  on  the  course  of  the  New  York  City 
epidemic  in  the  various  boroughs. 

It  is  evident  that  the  course  of  the  epidemic  has  been  at  first  gradual 
and  later  has  shown  an  increased  rate  of  acceleration  till  the  maximum  daily 
incidence  is  reached ;  after  this  the  decline  has  followed  an  inverse  direc- 
tion. In  New  York  City  this  rate  of  acceleration  has  been  greatest  in  the 
Borough  of  Richmond,  pro'ducing  a  higher  incidence  in  this  borough  till 
late  in  the  season  when  its  incidence  was  exceeded  by  that  of  the  Borough 
of  Queens.  This  rate  seems  to  be  much  more  rapid  in  the  more  rural  por- 
tions of  the  city,  even  in  the  more  sparsely  settled  portions  o'f  the  Bronx. 
It  is  also  very  evident  that  the  early  start  of  the  Brooklyn  epidemic  is 
casually  related  to  its  earlier  decline,  while  the  subsequent  appearance  of 
the  epidemic  in  Manhattan  and  Bronx  is  resulting  in  a  later  decline  in  these 
boroughs,  in  the  same  order  as  that  in  which  they  were  attacked. 

This  makes  it  appear  almost  unquestionable  that  there  is  a  very  definite 
period  required  for  an  epidemic  to  develop  and  subside  and  that  this  period 
has  been  almost  identical  in  length  this  summer  for  the  several  boroughs. 
When  this  is  taken  in  connection  with  the  late  development  of  the  epidemic 
in  Massachusetts  and  its  later  persistence  in  that  state  in  spite  of  cooler 
weather  than  prevails  in  New  York,  it  is  seen  that  summer  epidemics  are 
not  regulated  by  temperature  nor  by  insect  prevalence  alone.  It  seems 
equally  evident  that  one  or  more  factors  necessary  to  produce  an  epidemic 
are  not  present  in  the  winter  except  in  very  rare  instances.  However,  once 
an  epidemic  has  started,  it  appears  to  run  its  definite  predetermined  course 
even  though  this  may  be  prolonged  much  later  in  the  season  in  New  Eng- 
land than  in  southern  New  York.  From  these  facts  it  would  seem  that 
any  insect  responsible  for  the  spread  of  po'liomyelitis,  must  be  one  which 
remains  prevalent  much  longer  in  the  autumn  than  the  time  at  which  epi- 
demics usually  disappear.  The  stable-fly  and  fleas  of  various  sorts  would 
fit  this  requirement,  The  majority  of  other  insects  do  not  appear  to  do  so 
satisfactorily  on  account  of  their  more  rapid  disappearance  upon  the  ap- 
proach of  autumn  in  our  climate. 

Conclusions. 

Some  new  facts  of  interest  and  importance  relating  to  the  possible 
transmission  of  poliomyelitis  by  insects  have  resulted  from  the  present 
study,  but  these  are  not  so  definite  or  complete  as  had  been  hoped.  They 
are  also  to  some  extent  of  apparently  conflicting  nature,  and  require  at  least 
one  unproven  assumption  to  combine  them  into  any  working  hypothesis. 
They  do  not  completely  disprove  the  idea  that  the  stable-fly  (Stomoxys  cal- 
citrans)  is  implicated,  although  the  behavior  of  the  present  epidemic  does 
not  favor  this  view.     To  discard  it  is  to  cast  aside  evidence  derived  from 


163 

two  sets  of  experiments,  however,  and  it  seems  very  unwise  to  do  this  at 
the  present  time  of  uncertainty.  As  has  been  shown,  it  is  possible  with  one 
assumption  to  form  a  working  hypothesis  based  upon  rats  and  fleas  which 
seem  to  fit  the  epidemiological  observations  in  general  features  and  in  many 
details  as  well.  The  assumption  that  the  rat  can  act  as  a  reservoir  for  the 
virus  of  poliomyelitis  should  be  capable  of  experimental  proof,  and  it  would 
seem  that  such  experiments  should  be  attempted. 

This  by  no  means  precludes  the  association  of  some  other  insect  or 
warm-blooded  animal,  or  both.  In  fact,  there  is  a  continual  appearance  of 
circumstantial  evidence  that  suggests  a  population  other  than  the  human 
one,  acting  as  an  undercurrent  and  influencing  the  progress  of  the  epidemic. 

When  the  many  factors  so  far  in  doubt  are  gradually  made  known,  it 
will  be  possible  to  attack  the  entomological  side  of  the  question  with  better 
promise  of  success.  Among  the  unknown  factors  which  cause  the  greatest 
confusion  in  interpreting  epidemiological  evidence  are  (1)  the  length  of 
the  period  of  incubation  (2)  the  number  of  mild,  abortive  or  unrecognizable 
cases  and  carriers  of  the  virus  and  their  relation  to  infection  and  immunity ; 
(3)  the  duration  of  infectivity  in  clinically  recognized  cases;  and  (4)  posi- 
tive knowledge  of  the  presence  of  the  infective  agent  in  insects,  domestic 
animals,  or  other  possible  intermediate  hosts  or  reservoirs  of  the  virus. 


"IS  HXNaaiHnod 


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47  acres 
Pop.  3,900 
8  cases 
2.0  per  1,000 


50  acres 
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25  cases 
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47  acres 
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3  cases 
0.8  per  1.000 


47  acres 
Pop.  6,600 
6  cases 
0.9  per  1.000 


in 


Amsterdam  Ave. 

Population  20,800;  42  cases;  incidence  2.0  per  1,000. 

Map  2.— Area    on    the    upper  west  side  of  Manhattan  where  there  was  an 
extensive  outbreak  of  poliomyelitis. 


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■"■"■"■^~  ■  ^~ 

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Poliomyelitis  1586  oases Diphtheria  796  cases     Scarlet  fever  652  cases 

Fig.  2. — ^Chart  showing  the  prevalence  of  poliomyelitis,  diphtheria  and  scarlet  fever  on  the 
various  floors  of  dwellings  in  Manhattan.  The  number  of  cases  is  shown  by  the  figures  at  the 
left  of  the  chart,  and  the  percentage  of  cases  upon  a  given  floor  is  shown  by  the  figures  placed 
in  the  vertical  columns. 


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Fig.  4.— Distribution  of  857  cases  of  poliomyelitis   on  the  various  floors  of 
dwellings  in  Brooklyn.     Figures  at  the  left  indicate  number  of  cases. 


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CHAPTER   VI. 
Poliomyelitis  in  New  York  State  in  1916. 

Summary  of  Epidemiological  Data. 

The  following  data  are  abstracted  by  permission  from  the  Preliminary 
Report  of  the  State  Department  of  Health  on  Poliomyelitis  in  New  York 
State  in  1916: 

Poliomyelitis  was  made  a  reportable  disease  in  this  State  in  1910,  but 
no  extensive  outbreak  occurred  until  1912,  namely,  that  which  began  in 
Buffalo  and  spread  eastward.  This  outbreak  started  in  June,  reached  its 
height  in  August,  and  ceased  in  October,  resulting  in  a  total  number  of  306 
cases. 

In  Batavia,  about  thirty-five  miles  to  the  east  of  Buffalo,  the  outbreak 
began  in  August  and  stopped  in  October ;  a  total  number  of  26  cases  was 
reported.  Since  1912  many  cases  of  poliomyelitis  have  been  reported  from 
various  parts  of  the  State,  chiefly  from  the  western  portion,  60%  being  re- 
ported in  the  western  third  of  the  State,  representing  36.6%  of  the  popula- 
tion outside  New  York  City. 

Total  Number  of  Cases  and  Deaths  of  Poliomyelitis  in  New  York  State  Since  1910. 


Exclusive  of 

New 

York 

City. 

Year. 

Cases. 

Deaths. 

Cases. 

Deaths. 

1910 

112 

58 

112 

1911 

139 

52 

139 

1912 

1,108 

183 

604 

1913 

491 

123 

181 

66 

1914 

224 

68 

96 

29 

1915 

257 

50 

162 

34 

1916 

*12,574 

3,331 

**3,S65 

81 

♦Corrected  figures   (Jan.  15,  1917),  13,164  total  cases. 
**Corrected  figures    (Jan.  15,  1917),  4.155  total  cases  (excluding  New  York  City). 

Cases  appeared  in  various  parts  of  the  State  during  1916.  The  epi- 
demic was  not  recognized  until  the  latter  part  of  June,  when  the  outbreak 
occurred  in  New  York  City.  The  disease  spread  rapidly  to  the  counties 
surrounding  the  city,  Nassau  and  Westchester,  and  then  followed  the  lines 
of  travel  up  the  Hudson  River,  along  the  Mohawk  Valley  westward  to  Syra- 
cuse, theii  it  extended  northward  into  the  western  counties  of  the  State. 
The  largest  weekly  number  of  cases  reported  in  Nassau  County  occurred 
during  the  week  of  August  13th  to  19th;  in  Onondaga  County,  two  weeks 
later;  and  in  St.  Lawrence  County  during  September  10th  to  16th. 


180 


The  table  given  below  indicates  the  incidence  of  the  disease  by  weeks 
and  months  for  the  months  of  June,  July,  August,  September  and  October : 


June. 

A, 

July. 

August. 

September. 

October. 

Weeks 

.  Cases. 

Weeks. 

Cases. 

Weeks. 

Cases. 

r 

Weeks. 

Cases. 

Weeks.  Cases. 

1-6 

3 

4-10 

71 

7-13 

421 

4-10 

336 

3-8,        143 

7-13 

2 

11-16 

86 

14-20 

482 

11-17 

259 

9-15        92 

14-20 

3 

17-23 

182 

21-27 

428 

18-24 

244 

16-22        62 

21-27 

15 

24-30 

229 

28-3 

378 

25-1 

169 

23-29        ZZ 

28-3 

31 

31-6 

351 

30-4         25 

N.  Y. 

State 

and  City  54 

929 

1,709 

1,008 

355 

N.  Y. 

City 

335 

4,373 

2,335 

878 

315 

This  table  shows  that  the  disease,  commencing  in  June,  gradually  in- 
creased during  July  and  reached  its  maximum  incidence  in  August,  about 
the  middle  of  the  month,  having  attained  its  height  a  little  earlier  in  the 
City  of  New  York,  and  that  after  that  time  it  steadily  declined,  until  by  the 
end  of  October  there  were  comparatively  few  cases  reported. 

The  total  number  of  cases  reported  in  the  State,  up  ta  January  1st, 
1917,  was  13,164,  of  which  4,165  occurred  outside  New  York  City. 

The  following  curve  indicates  the  general  incidence  of  the  disease  by 
weeks  during  June,  July,  August,  September  and  October.  The  map  shows 
where  the  cases  were  located. 


/ 

^ 
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•-> 


ff      - 


Distribution  of  Cases  of  Poliomyelitis  in  New  York  State,  outside  of  the  City  of  New  York^ 

ON  September  30,  1916 


185 

An  exact  idea  of  the  case  fatality  of  the  disease  cannot  be  given  on 
account  of  the  large  number  of  non-paralytic  or  abortive  cases  which  were 
unrecognized  and  not  reported.  From  June  1st  to  November  1st,  there  were 
reported,  outside  New  York  City,  3,554  cases  with  844  deaths,  making  a 
fatality  rate  of  23.7%.  In  New  York  City,  during  the  same  period,  there 
were  8,928  cases  reported  with  2,407  deaths,  making  a  fatality  rate  of 
26.96%.  In  the  State  there  were,  therefore,  reported  12,482  cases,  of  which 
3,251  died,  or  26  plus  per  cent.* 

As  soon  as  it  was  realized  that  an  outbreak  of  poliomyelitis  was  immi- 
nent, the  State  Department  of  Health  instituted  an  active  sanitary  cam- 
paign, and  provided  the  necessary  organization  and  equipment  to  carry  out 
adequate  measures  to  prevent  the  spread  of  the  disease. 

A  special  investigation  was  made  of  the  epidemiology  of  poliomyelitis, 
the  results  of  which  accord  very  much  with  those  obtained  by  the  Depart- 
ment of  Health,  New  York  City.  Regarding  the  prevention  of  the  disease, 
the  conclusion  was  reached  "  that  it  will  not  be  possible  to  establish  ade- 
quate and  precise  measures  for  the  control  of  this  disease  until,  first,  the 
limits  of  the  reservoirs  of  infection  in  nature  are  definitely  known;  and 
second,  until  the  exact  means  of  transmission  has  been  worked  out." 

In  an  exhaustive  study  of  1,081  cases  of  poliomyelitis,  these  points  are 
emphasized : 

1.  577  were  males  and  504  were  females. 

2.  The  age  incidence  having  the  largest  number  of  cases  was  2  years ; 

49%  were  under  5  years  of  age. 

44  cases  were  under     1  year. 

106  cases  were  over  1  year  old,  but  under  2. 
188  cases  were  over  2  years  old,  but  under  3. 
126  cases  were  over  3  years  old,  but  under  4. 
121  cases  were  over    4  years  old,  but  under    5. 

87  cases  were  over    5  years  old,  but  under    6. 

84  cases  were  over    6  years  old,  but  under    7. 

37  cases  were  over    7  years  old,  but  under    8. 

45  cases  were  over  8  years  old,  but  under  9. 
47  cases  were  over  9  years  old,  but  under  10. 
16  cases  were  over  10  years  old,  but  under  11. 
21  cases  were  between  11-15  years  old. 

44  cases  were  between  16-20  years  old. 

38  cases  were  between  21-25  years  old. 
19  cases  were  between  26-30  years  old. 

3  cases  were  between  31-35  years  old. 
3  cases  were  between  36-40  years  old. 

1  case  was  between  41-45  years  old. 

2  cases  were  over  50  years  old. 

*  These  figures  to  be  corrected  later  v/hen  additional   data  have  been  collected 
through  the  poliomyelitis  clinics  held  periodically  throughout  the  State. 


186 


3.  Associated  in  the  families  with  poHomyehtis  with  those  1,081  cases 
were  2,579  children,  and  3,511  adults,  making  a  total  of  6,090  exposed  per- 
sons. Of  the  1,081  cases  only  24  were  associated  with  other  cases  in  the 
same  family. 

4.  In  131  instances  the  patient  was  a  visitor  from  out  of  town. 

5.  Information  about  the  financial  status  of  the  family  was  obtained 
in  445  instances.  Of  these,  140  were  in  families  of  the  poor,  260  families 
were  in  moderate  circumstances,  and  45  families  of  the  well-to-do. 

6.  There  seems  to  have  been  no  relation  between  sanitary  conditions 
and  the  incidence  of  cases.  Sanitary  conditions  were  bad  at  the  homes  of 
156  cases,  fair  in  302,  good  in  340,  and  excellent  in  215  cases. 

7.  The  previous  health  of  the  patient  had  been  poor  in  68  cases,  fair 
in  18  cases,  good  in  372  cases,  and  excellent  in  512  cases. 

8.  Paralysis  appeared  before  the  4th  day  of  the  disease  in  71^  of 
700  cases  as  follows  : 


189  had 

paralysis 

on  the 

1st 

day 

of 

illness. 

203  had 

paralysis 

on  the 

2nd 

day 

of 

illness. 

142  had 

paralysis 

on  the 

3rd 

day 

of 

illness. 

85  had 

paralysis 

on  the 

4th 

day 

of 

illness. 

48  had 

paralysis 

on  the 

5th 

day 

of 

illness. 

29  had 

paralysis 

on  the 

6th 

day 

of 

illness. 

20  had 

paralysis 

on  the 

7th 

day 

of 

illness. 

14  had 

paralysis 

on  the 

8th 

day 

of 

illness. 

6  had 

paralysis 

on  the 

9th 

day 

of 

illness. 

3  had 

paralysis 

on  the 

10th 

day 

of 

illness. 

2  had 

paralysis 

on  the 

11th 

day 

of 

illness. 

2  had 

paralysis 

on  the 

12th 

day 

of 

illness. 

1  had 

paralysis 

on  the 

13th 

day 

of 

illness. 

4  had 

paralysis 

on  the 

14th 

day 

oi 

illness. 

1  each 

on  the  15th,  16th 

20th  and  2 

Lst  days. 

9.  The  nationality  of  the  parents  was  largely  American.  709  fathers 
and  700  mothers  were  born  in  the  United  States ;  70  fathers  and  61  mothers 
were  Italians. 

10.  Animals  on  the  premises :  There  were  horses  present  on  141 
premises,  cows  on  151  premises,  sheep  on  1,  dogs  on  162,  cats  on  189,  pigs 
on  79,  goats  on  5,  and  fowls  on  284. 

The  following  general  observations  on  the  outbreak  as  a  whole  are 
of  interest: 

I. — "  The  onset  of  the  epidemic  was  in  New  York  City,  which 
gradually  spread  up-state.  The  most  heavily  infected  region  was  on 
the  southeast  corner  of  the  State.  The  height  of  the  epidemic  ap- 
peared in  Nassau  and  Westchester  Counties  in  August,  while  in  the 
upper  counties  of  the  State  it  appeared  in  September."       


187 

II. — "  The  cases  seemed  to  follow  the  course  of  railroads,  indi- 
cating that  travel  may  have  had  something  to  do  with  the  spread  of 
the  disease." 

III. — "  No  milk-borne  outbreaks  of  poliomyelitis  were  reported. 
(Neither  were  there  any  milk-borne  outbreaks  of  scarlet  fever  and 
typhoid  during  the  same  period.)  The  same  safeguards  were  used 
on  dairy  farms  where  cases  of  poliomyelitis  existed  that  were  em- 
ployed when  typhoid^  fever  or  scarlet  fever  occurred.  Poliomyelitis 
was  reported  on  112 'farms  during  the  summer." 

IV. — "  No  water-borne  outbreaks  of  poliomyelitis  were  noted." 

V. — "  The  seasonal  prevalence  corresponds  to  that  of  typhoid 
fever.  The  largest  number  of  cases  were  reported  in  August.  In 
previous  years  the  largest  number  of  cases  had  been  reported  in 
September." 

VI. — "  It  is  difficult  to  estimate  the  exact  value  of  the  quarantine 
measures  adopted.  In  many  instances  quarantine  measures  have  been 
enforced  vigorously  and  in  other  places  with  laxity.  But  because 
adults  were  not  restricted  it  is  evident  that  only  a  partial  quarantine 
was  maintained.  It  is  significant  that  institutions  located  in  the  midst 
of  infected  districts  where  complete  quarantine  was  rigidly  main- 
tained have  been  free  from  infection." 

The  factors  demanding  special  attention  are  pointed  out  to  be :  a  simple 
method  o'f  detecting  the  infectious  agent,  or  at  least,  of  detecting  where  it 
is  located;  a  careful  study  of  small  groups  of  cases  in  order  to  determine 
what  part  of  the  material  transferred  from  the  nose  and  throat  and  alvine 
discharges,  from  one  person  to  another,  has  to  do  with  the  incidence  of  the 
disease;  a  careful  study  as  to  what  constitutes  immunity  from  this  disease 
— who  are  immune  and  why ;  an  entomological  survey  of  the  homes  occu- 
pied by  small  groups  of  cases  to  determine  the  common  insect  life  in  these 
homes. 


CHAPTER  VII. 
Pathology. 

The  morbid  anatomy  of  acute  poHomyeHtis  has  received  careful  and 
painstaking  study  by  a  number  of  European  pathologists,  chief  among 
whom  are  Wickman,  with  a  study  of  fourteen  cases,  Harbitz  and  Scheel* 
with  nineteen  cases,  and  Strausj  with  eight  cases.  The  findings  by  all  of 
these  workers  happily  coincide,  so  that  this  phase  at  least  of  the  poliomye- 
litis study  may  be  said  to  be  practically  settled  and  free  from  conjecture. 

Because  of  the  importance  of  functional  diagnosis  and  the  primary  in- 
terest in  connecting  the  physical  signs  and  clinical  findings  with  the  morbid 
anatomical  lesions  as  disclosed  at  autopsy,  the  emphasis  in  the  reports  has 
usually  been  put  upon  the  character  and  location  of  the  lesions  in  the 
central  nervous  system.  This  has  led  to  a  false  conception  of  the  true  nature 
of  the  disease  which  from  the  general  distribution  of  the  lesions  among 
the  lymphatic  and  glandular  tissues  of  the  body,  as  well  as  in  the  brain 
and  spinal  cord,  should  be  that  of  a  general  infection  with  the  commonest 
focal  symptoms  resulting  from  the  damage  to  the  anterior  horns  in  the 
cord.  Many  of  the  general  symptoms  and  not  a  few  of  the  clinical  signs 
of  value  particularly  in  the  early  preparalytic  stage  of  the  disease,  result 
from  the  general  invasion  of  the  body  and  particularly  the  lymphatic 
tissues.  It  is  important  to  the  further  study  and  early  recognition  of  non- 
paralytic cases  that  the  general,  rather  than  the  purely  central  nervous 
system  lesions  of  the  disease  be  accepted  as  essential  and  typical. 

In  the  present  epidemic,  post-mortem  examinations  were  performed  by 
pathologists  of  the  Research  Laboratory  of  the  Department  on  forty  cases 
of  poliomyelitis,  thirty-eight  of  which  died  in  the  acute  stages ;  thirty-six 
were  cases  from  the  Willard  Parker  Hospital,  and  four  were  done  in  private 
residences.  Nine  other  cases  came  to  autopsy  from  the  poliomyelitis 
hospital  wards,  four  of  these  proved  to  be  tuberculous  meningitis ;  one 
broncho  pneumonia ;  one  congenital  heart  disease ;  one  purulent  pericarditis 
with  purulent  pleuritis,  broncho  pneumonia,  and  general  pyemia;  and  one 
intracranial  hemorrhage.  The  poliomyelitis  cases  confirmed  at  autopsy,  are 
divided  as  to  sex,  age,  and  duration  of  illness : 

Sex — Male,  37;  Female,  13. 
Age 
Up  to  1  year  8 

1  to  2  years 8 

2  to  3  years  13 

*  Harbitz  and  Scheel :  Patholoisrisch-anatomische  Untersuchungen  ueber  akute 
Poliomyelitis,  Vidensk  Selsk.  Skr.,  Christiania.  1907. 

t  Straus :  Report  of  Collective  Investigation  Committee  in  the  N.  Y.  Euidemic 
of  Poliomyelitis,  1907— Jour,  of  Nerv.  &  Ment.  Dis.,  Monograph  Series,  206,  1910. 


189 

Age. 

3  to  5  years  2 

5  to  10  years  3 

10  to  16  years  1 

Over  16  years    5 

Up  to  and  including  5  years  there  was  a  total  of  31  or 
77.5%. 

Duration  of   Illness — 

3  days   10 

4  days   5 

5  days 6 

6  days    5 

7  days   5 

8  to  11  days 3 

Over  12  days  4 

Undetermined  number  of  days 2 

31  or  77.5%  of  the  cases  died  v^ithin  the  first  week 

after   onset. 

The  cHnical  classification  as  to  type  is  based  on  the  evidence  of  anatom- 
ical lesions.  Thus,  all  cases  exhibiting  involvement  of  the  lower  motor 
neurone  were  called  spinal  cases.  These  were  again  divided  into  two 
classes ;  one  in  which  the  process  begins  in  the  lumbo-sacral  cord  and 
progresses  upward  involving  the  arm  and  respiratory  centres,  and  the  other 
in  which  the  process  begins  in  the  cervical  bulbar  regions  or  in  the  gray 
matter  from  which  the  cranial  nerves  have  their  origin. 

Those  cases  exhibiting  disturbance  of  the  upper  motor  neurone  or 
other  disturbances  of  the  sensorium  belong  to  the  cortical  type.  Those 
cases  showing  only  marked  meningeal  symptoms  were  considered  to  be 
of  the  meningitic  variety.     They  are  as  follows : 

Types  of  Cases. 

Ascending  spinal    16 

Upper  spinal    18 

Cortical    3 

Meningitic    3 

One  of  the  ascending  spinal  cases  survived  the  poliomyelitis  infection 
and  died  of  lobar  pneumonia  thirty-four  days  after  the  onset  of  illness. 
Another  case  belonging  to  the  upper  spinal  group  died  of  acute  gastro- 
enteritis twenty-eight  days  after  the  onset  of  the  polio-infection. 

The  gross  changes  when  in  the  brain  were  usually  those  of  varying 
grades  of  congestion  of  the  pial  and  parenchymatous  vessels;  of  edema 
of  the  pia  and  brain  substances.  In  a  few  instances  the  brain  tissue  was 
of  softer  consistency  than  normal.     One  brain,  in  a  man  of  twenty-seven 


190 

years,  besides  intense  congestion  of  the  edema,  presented  extreme  softening 
m  one  hemisphere  involvmg  the  motor  area  and  a  great  portion  of  the 
parietal  lobe,  in  which  lies  the  sensory  area.  Clinically,  this  man  presented 
a  hemiplegia  and  hemianesthesia  of  the  opposite  side.  The  brain  tissue 
was  reduced  to'  a  mushy  consistency  with  multiple  hemorrhagic  flecks 
throughout  the  cut  surface.  No  gross  hemorrhage  was  visible  and  the 
spinal  fluid  was  clear,  with  changes  such  as  one  would  find  in  poliomyelitis. 
The  Wassermann  reaction  was  negative.  This  is  the  only  cortical  case 
simulating  apoplexy  that  came  under  observation,  at  the  Willard  Parker 
Hospital,  among  a  great  number  of  cases.  The  changes  in  the  spinal  cord 
were  observed  commonly  on  cut  sections  through  the  pons,  medulla  and 
upper  cervical  portion,  it  being  our  intention  to  preserve  as  much  material  as 
possible,  in  a  clean  state,  for  cultures,  microscopic  study  and  animal  experi- 
mentation. The  cut  sections  presented  degrees  of  hyperemia  and  swelling 
of  the  gray  matter.  The  gray  matter  bulges  above  the  level  of  the  sur- 
rounding white  matter  and  is  sharply  demarcated  from  it.  In  marked  cases, 
the  gray  matter  would  be  very  red,  and  in  some  there  were  what  appeared 
to  be  small  punctate  hemorrhages.  In  other  cases,  the  gray  matter  is 
simply  pink-tinged  and  easily  marked  off  from  the  surrounding  white 
matter.  Sections  through  normal  cords  fail  to  show  the  ready  differentia- 
tion between  gray  and  white  matter  which  is  to  be  observed  in  cords  from 
poliomyelitis  infection.  In  some  cases  the  edema  involved  the  white  matter 
as  well,  and  appeared  to  soften  the  cord  as  a  whole. 

The  heart  and  lungs  showed  no  striking  changes  except  that  practically 
all  of  the  lungs  presented  acute  edema  and  congestion  incident  to  the 
paralysis  of  respiration. 

The  liver  and  kidneys  showed  varying  degrees  of  acute  congestion  and, 
in  some  cases,  parenchymatous  degeneration. 

Particular  attention  was  paid  to  the  lymphatic  structures  as  some 
observers  contend  that  lymphoid  tissue  plays  a  considerable  role  in  the 
pathologic  picture  of  acute  poliomyelitis.  The  lymphoid  structures  of  the 
small  intestines,  the  Peyer's  patches  and  solitary  follicles,  in  a  number  of 
instances,  exhibited  proliferation  and  congestion.  The  mesenteric  lymph- 
nodes  were  enlarged  and  reddened.  The  spleen,  in  many  instances,  showed 
marked  congestion  and  varying  degrees  of  hyperplasia  of  the  malpiehian 
bodies.     Following  is  a  tabulation  of  g-ross  changes  as  above  described : 

Not  Noted 
Present.     Absent,    or  Examined. 

Brain    3'^  5 

Cord    20  5  IS* 

Intestine 16  8  16 

Mesenteric  Nodes    19  10  11 

Spleen    18  16                 6 


Showed  no  changes  at  the  level  of  the  sections  made. 


191 

A  number  of  the  autopsies  were  granted  only  for  the  examination  of 
the  brain  and  cord,  and  this  fact  accounts  for  the  incompleteness  of  the 
data  as  to  the  other  organs. 

The  microscopic  pictures  of  our  cases  are  now  in  process  of  study. 
Such  as  have  been  looked  over  correspond  with  those  so  carefully  described 
by  Wickman,  Harbitz  and  Scheel,  et  al.  The  changes  in  the  affected 
portions  consist  chiefly  in  a  perivascular  round  cell  infiltration,  engorgement 
of  the  blood  vessels,  edema  of  the  interstitial  tissue  and  destruction  of  nerve 
cells. 

The  pia  mater  is  affected  most  commonly  in  the  sacral  and  lumbar 
regions,  though  congestion  of  the  vessels  and  infiltration  of  cells  about 
them  may  be  found  in  any  section  of  the  cord.  The  gray  matter  of  the 
anterior  horns  show,  as  a  rule,  the  most  marked  changes,  though,  in  some 
cases,  the  posterior  horns,  especially  the  gray  matter  of  Clark's  column, 
may  be  densely  infiltrated.  Those  sections  which  are  the  first  to  bear  the 
brunt  of  the  attack,  as  a  rule,  show  the  severest  changes  in  the  ascending 
spinal  cases,  usually  the  sacral  and  lumbar  region ;  in  the  upper  spinal  type, 
the  cervical  region,  the  gray  matter  about  the  floor  of  the  fourth  ventricle 
and  aqueduct  of  Sylvius. 

In  the  brain,  the  regions  most  seriously  affected  are  the  basal  ganglia, 
though  the  cortex  at  all  times  shows  changes,  most  marked,  usually,  in  the 
motor  areas.  The  intervertebral  ganglia,  in  some  cases,  have  shown 
changes  similar  to  those  seen  in  the  gray  matter  of  the  cord  and  brain. 

The  cell  types,  which  go  to  make  up  the  infiltrated  mass,  consist 
chiefly  of  polymorphonuclears,  lymphoid  and  cells  derived  from  the  lymphoid 
cells  called  poly-blasts.  These  latter  cells  have  a  relatively  larger  amount 
of  protoplasm  than  the  lymphocytes  and  its  nucleus  is  paler  staining  and 
fasiculated.  This  cell,  as  well  as  the  polymorphonuclear  cell,  exhibit  the 
function  of  neuronaphagia,  that  is,  they  break  up  and  carry  away  nerve 
cells  that  have  been  destroyed  by  the  virus  of  the  disease.  They  can  be 
seen  in  the  process  of  invading  the  damaged  nerve  cells,  fragmenting  it 
and  carrying  off  the  debris.  As  to  the  source  of  these  cells,  different 
authors  have  different  opinions.  Some  think  they  are  derived  from  the 
white  cells  of  the  blood ;  others  that  they  are  produced  by  a  proliferation 
of  the  fixed  cells  of  the  adventitia  of  blood  cells ;  others  that  they  are 
derived  from  the  neuroglia  of  the  central  nervous  system. 

While  the  cell  infiltration  is,  as  a  rule,  most  marked  about  the  blood 
vessels,  forming  a  cellular  collar  about  them,  as  it  were,  there  are  to  be 
noted  marked  diffuse  infiltrations  as  well.  The  nerve  cells,  in  the  neighbor- 
hood of  most  of  these,  indicated  degenerative  changes.  The  cell  body 
swells,  and  becomes  more  globular.  A  disintegration  if  Nissl's  granules 
occurs.  If  the  process  extends,  the  nucleus  is  converted  into  a  deeply 
stainin?  irregular  shaped  structure.  Sometimes  complete  destruction  of 
nucleus  takes  place.  After  this  happens,  the  neurophages  enter  and  clear 
awav  the  debris. 


192 

The  edema,  when  marked,  converts  the  neurogha  into  pale  staining 
granular  mass.  The  bundles  of  nerve  fibres,  in  the  white  matter,  are  separ- 
ated by  the  accumulation  of  fluids  between  them.  It  is  this  factor  that  has 
to  be  reckoned  with  in  the  explanation  of  the  transient  paralyses  that  occur 
in  this  disease.  No  large  extravasations  of  blood  are  to  be  seen.  Here 
and  there,  small  accumulation  of  red  cells  have  apparently  broken  through 
a  thin  capillary  wall.  These  minute  hemorrhages  would  not  show  up  on 
gross  inspection.     So  much  for  the  stage  of  destruction. 

In  the  reparative  stage,  there  is  recession  of  cell  infiltration,  disappear- 
ance of  the  edema  and  congestion.  The  neurophages  are  carrying  off  the 
destroyed  nerve  cells.  There  is  a  proliferation  of  the  neuroglia  tissue 
which  gradually  replaces  the  destroyed  nerve  element.  As  this  neuroglia 
ages,  it  contracts  and  so  forms  the  scars  which  are  to  be  seen  on  sections 
of  the  cord  from  old  cases  of  poliomyelitis.  As  a  result  of  the  destruction 
of  the  nerve  cells  of  the  anterior  horns,  there  is  a  secondary  degeneration 
of  the  peripheral  nerve  fibre,  and  a  consequent  atrophy  of  the  muscle  sup- 
plied by  that  fibre.  The  upper  motor  neurone,  which  connects  with  the 
nerve  cell  in  the  anterior  horn,  also  undergoes  atrophy  because  of  lack  of 
function. 

The  microscopic  changes  in  the  lymphatic  structure  consist,  generally, 
of  an  acute  congestion,  with  hyperplasia  of  round  cells,  such  a  picture  as 
one  may  find  in  any  generalized  infection. 

The  pathogenesis  of  poliomyelitis  is  still  an  open  question  among 
pathologists.  Some  think  that  the  virus  has  a  direct  destructive  effect  upon 
the  nerve  cell,  and  that  the  vascularity,  edema  and  round  cell  infiltration 
are  only  the  evidence  of  the  body  reaction  to  the  presence  of  the  virus. 
Another  school  of  workers  considers  nerve  cell  degeneration  secondary  to 
the  marked  inflammatory  reaction ;  in  other  words,  that  the  nerve  cell  is 
destroyed  in  a  mechanical  wav  by  the  effect  of  pressure  of  the  engorged 
vessels,   edema   and   cellular   infiltration. 

We  agree  with  the  opinion  of  that  school  of  pathologists  which  con- 
siders the  virus  a  specific  nerve  cell  poison,  in  a  manner  analogous  to  the 
virus  of  rabies,  tetanus  and  diphtheria  toxin.  If  one  concedes  that  the 
infection  is  principally  manifested  by  disease  of  the  central  nervous  system, 
and  this  is  the  consensus  of  opinion,  then  one  must  alsa  concede  that  it  is 
the  active  elements  of  the  brain  and  cord,  namely,  the  nerve  cells,  which 
have  special  affinity  for  the  virus  of  poliomyelitis. 

It  is  probable,  however,  that  edema  and  congestion  play  a  considerable 
part  in  the  production  of  the  transient  paralysis  observed  in  this  disease. 
With  the  recession  of  the  edema  and  congestion,  nerve  cells,  which  have 
been  rendered  temporarily  incapable  of  performing  their  functions,  are 
restored  to  their  normal  state. 

Two  factors  in  the  pathogenesis  of  this  disease,  the  specific  cell  poison 
and  edema  and  congestion,  are  necessary  to  explain  the  commonly  observed 
clinical  manifestations  of  acute  poliomyelitis. 


193 

As  indicating  the  location  of  the  lesion  which,  in  the  great  majority  of 
the  cases,  appears  to  determine  the  fatal  issue,  the  following  summary  is 
included,  giving  the  result  of  a  study  of  1,500  of  the  fatal  cases,  by  imme- 
diate personal  inquiry  and  verification  of  the  clinical  history  and  record  as 
soon  as  the  death  certificate  was  received  at  the  Department  of  Health. 

Death  was  attributed  in  61^  of  the  cases  directly  to  respiratory  failure. 

In  35^  more  cardiac  failure  appeared  to  share  in,  if  not  actually  to 
dominate  the  picture  as  the  cause  of  death,  but  in  these  cases  also  respiratory 
failure  was  a  serious  factor. 

In  4^  death  resulted  from  other  causes  superimposed  upon  poliomye- 
litis, as  in  specific  instances,  pneumonia,  cerebral,  hemorrhage,  and  gastro- 
enteritis. 

Among  1,390  of  the  1,520  cases  which  were  thus  studied  and  in  which 
the  data  w^ere  sufificiently  complete  to  be  trusted,  there  were  79  patients  in 
whom  the  paralysis  appeared  to  have  been  limited  to  the  muscles  of  respira- 
tion, 456  in  whom  paralysis  existed  in  other  groups  of  muscles  as  well  as 
in  the  respiratory  group.  There  were  58  in  whom  the  muscles  of  the 
pharynx  and  larynx  alone  appeared  to  be  involved,  and  354  more  where 
these  muscle  groups,  as  well  as  muscles  of  the  trunk  and  extremities  were 
involved. 

Of  these  same  1,390  cases  it  is  recorded  that: 

In  258  there  was  paralysis  of  all  four  extremities. 

In    52  there  was  paralysis  of  three  extremities. 

In  443  there  was  paralysis  of  two  extremities. 

In  266  there  was  paralysis  of  one  extremity. 

In  the  appendix  will  be  found  a  table  (XXII)  summarizing  the  proto- 
cols of  each  autopsy. 

Pathological  Conditions  of  Nose  and  Throat. 

In  view  of  the  fact  that  the  nose  and  throat  are  believed  to  be  the  chief 
modes  of  entrance  to  the  body  of  the  virus  of  poliomyelitis,  the  question 
naturally  arises — what  proportion  of  these  organs  show  actual  pathological 
conditions  ?  In  order  to  answer  this  question  definitely,  a  special  study 
of  2,000  poliomyelitis  patients  in  the  Department  Hospitals  was  made  by 
one  of  our  most  expert  laryngologists. 

The  results  of  the  investigation  are  tabulated  below: 

Age  Ratio 

Percentage  Age  Ratio 

Age  of  Cases  Examined.                                    0/2000  Total 

Cases.  Epidemic. 


Number  of  cases 
examined  2,000 


fUptolyear 279  13%  10% 

Over  1  year  up  to  5  years  of  age,  1,392  72%  75% 
Over  5   years.     Under   16  years 

(school  age) 244  12%  12% 

[Over  16  years  of  age 40  2%                 1.9% 


194 


Patho- 

Adenoids 

Cases 

Percentage 

logical 

only  or 

Cases 

with 

Ratio 

Condition 

Retro- 

with 

Patho- 

Patho- 

Tonsils 

pharyngeal 

Number 

Normal 

logical 

logical 

and 

Obstruc- 

Ages.               Examined. 

Conditions.Conditions 

Cases. 

Adenoids. 

tion. 

Up  to  1  year 

279 

177 

102 

36.5% 

66 

36 

Over  1  year  up  to  5 

years  of  age 

1,392 

499 

893 

64.1% 

829 

64 

Over  5  years  under  16 

years  of  age 

244 

141 

103 

42.2% 

98 

5 

Over  16  years  of  age . . 

40 

33 

7 

17.5% 

7 

0 

Number  of  cases  without  previous  operation,  nose  or  throat 1,955 

Number  of  cases  completely  recovered  discharged  from  hospitals        550  out  of  3,800 

Percentage   Ratio 

Number  of  cases  having  previous  operation,  nose  or  throat 

Number  of  cases  completely  recovered  with  previous  operations.. 
Percentage   Ratio 


15% 

45 

19  out  oif  39 

46% 


Summary  of  Results. 

1.  A  large  number  of  children  with  poliomyelitis  show  pathological 
conditions  of  the  nose  and  throat,  either  diseased  and  hypertrophied  tonsils 
and  adenoids  or  both. 

2.  A  large  number  of  children  with  poliomyelitis  show  marked  hyper- 
emia of  the  naso-pharynx  and  throat  (tonsils  and  anterior  pillars  and 
soft  palate),  often  resembling  a  scarlet  or  streptococcus  throat. 

3.  Only  a  small  percentage  of  cases,  previously  operated  for  tonsils 
and  adenoids,  were  found  to  be  affected  with  the  disease,  and  in  that  group 
of  cases  the  percentage  of  recovery  was  very  much  higher  than  in  unoperated 
cases.  The  number  of  cases  in  this  group  is,  of  course,  rather  small  to 
draw  from  it  any  definite  conclusions,  but  it  is  at  least  suggestive. 

In  another  investigation  of  1404  children  in  the  public  schools,  made  to 
determine  whether  any  children,  whose  tonsils  had  been  removed,  had  been 
ill  with  poliomyelitis  during  the  recent  epidemic,  a  similar  result  was 
obtained.  The  investigation  was  conducted  by  trained  nurses,  under  the 
direction  of  an  experienced  District  Medical  Supervisor  of  the  Department, 
and  the  children  were  examined  in  thirty  public  schools. 

Following  is  a  list  of  the  number  of  children  operated  on  by  ages,  and 
of  the  date  of  operation : 

Number  of  Children  Operated  on,  by  Ages. 


5  years 

of 

age 

6  years 

of 

age 

7  years 

of 

age 

8  years 

ot 

age 

9  years 

ot 

age 

10  years 

of 

age 

11  years 

ot 

age 

12  years 

ot 

age. 

13  years 

ot 

age, 

14  years 

ot 

age, 

7 

87 

191 

271 

271 

220 

194 

157 

4 

2 


Total 


1,404 


195 


Date  of  Operations. 

Cases  operated  in  1916 299  (prior  to  epidemic) 

Cases  operated  in  1915 464 

Cases  operated  in  1914 323 

Cases  operated  in  1913 150 

Cases  operated  in  1912 112 

Cases  operated  in  1911 33 

Cases  operated  in  1910 13 

Cases  operated  in  1909 4 

Cases  operated  in  1908 4 

Cases  operated  in  1907 1 

Cases  operated  in  1906 1 

Total 1,404 

Of  the  1404  children  where  tonsils  had  been  operated  upon,  not  one 
developed  poliomyelitis  during  the  epidemic,  although  in  18  instances,  cases 
developed  in  the  family  and  in  93  instances,  cases  developed  in  the  same 
house. 


CHAPTER  VIII. 
Symptomatology. 

The  symptomatology  of  poliomyelitis  corresponds  to  what  one  would 
expect  from  a  consideration  of  the  pathology  of  the  disease  as  a  general 
infection,  with  the  lesions  most  marked  in  the  central  nervous  system.  The 
clinical  manifestations  exhibit  a  widespread  and  scattered  motor  paralysis 
or  weakening. 

The  large  majority  of  all  cases  are  of  the  well  known  spinal  form, 
but  there  are  many  variations  in  the  disease  described  by  Wickman*  as 
types,  in  which  the  symptoms  are  not  of  the  usual  kind.  His  classification 
and  description  of  these  types  have  enabled  us  to  recognize  clearly  the 
multiform  character  of  the  infection. 

Any  classification,  however,  of  a  disease  so  protean  in  its  manifesta- 
tions as  poliomyelitis  is  at  best  unsatisfactory,  as  no  one  classification  will 
cover  all  cases.  Wickman's  classification  of  the  affection  into  the  spinal 
progressive,  bulbar,  acute  encephalitic,  ataxic,  meningitic,  poly-neuritic  and 
abortive  types  is  comprehensive,  but  it  is  open  to  the  objection  that  it  is 
based  both  on  pathological  anatomy  and  symptomatology.  Moreover,  it 
is  rather  complicated  for  general  clinical  use.  Mueller'sf  classification  is 
simpler,  namely  that  of  spinal,  bulbar,  cerebral  and  abortive  forms.  Peabody, 
Draper  and  DochezJ  advocate  a  still  simpler  description,  namely,  abortive, 
cerebral  and  bulbo-spinal.  We  would  suggest  the  following  classification 
based  wholly  on  pathological  anatomy: 

1.  Non-paralytic  or  abortive  type — 

Under  this  head  are  included  cases  in  which  the  nerve  cells  are  not 
sufficiently  injured  to  produce  paralysis,  though  there  may  be  weakness. 
Under  this  type  also  should  be  classed  meningitic  cases  and  those  somewhat 
like  tuberculous  meningitis  but  without  motor  disturbance,  often  called 
encephalitic.  In  these  cases,  the  motor  cortical  areas  are  not  involved,  but 
there  is  evidence  of  disturbance  of  the  sensorium. 

2.  Ataxic  type — 

Here  the  motor  cells  are  evidently  not  involved,  but  there  is  a  lack  of 
co-ordination,  ataxia,  nystagmus,  etc.  The  anatomical  basis  for  this  is 
proved  by  post-mortem  findings  of  involvement  of  the  cerebellum,  Clark's 
column,  and  the  intervertebral  ganglia.     This  type  is  very  rare. 

3.  Cortical  type — 

The  upper  motor  neurone  is  here  affected  with  resulting  spastic  paral- 
ysis.    This  group  is  also  very  infrequent. 

*"Die  Akute  Poliomyelitis  "—Berlin,  1911. 
f'Die  Spinale  Kinder  Laehmung" — Berlin,  1910. 
J  Monograph  No.  4,  Rockefeller  Institute — 1912. 


197 

4.     Ordinary  spinal  or  sub-cortical  type — 

Here  the  lower  motor  neurone  is  affected  with  resulting  flaccid 
paralysis. 

A  manifestation  of  poliomyelitis  difficult  to  classify  is  blindness. 

The  most  important  symptoms  of  the  disease  may  be  described  under 
the  non-paralytic  or  abortive  cases,  and  those  of  the  ordinary  spinal  form. 

Non-Paralytic  Type. 

Non-paralytic  cases  are  very  frequent,  and  they  are  often  unrecognized 
and  unrecognizable.  In  some  epidemics  they  constitute  from  one-fourth 
to  one-half  of  the  diagnosed  cases.  Wickman  found  25  to  56  per  cent,  of 
non-paralytic  cases  in  the  total  incidence  of  the  disease,  and  he  considered 
these  figures  far  too  low.  Mueller  supports  him  in  this  opinion,  and  believes 
that  the  non-paralytic  cases  outnumber  the  cases  of  frank  paralysis. 

The  symptoms  in  the  non-paralytic  cases  include  those  of  general 
infection,  cases  with  meningeal  irritation,  cases  with  much  pain,  and  cases 
with  marked  digestive  disturbances.  The  characteristic  of  the  abortive 
cases,  however,  is  that  they  are  not  followed  by  a  frank  paralysis. 

As  early  symptoms  may  be  mentioned,  fever,  vomiting,  slight  diarrhoea 
or  constipation,  listlessness,  unusual  fretfulness  or  drowsiness.  Perhaps 
muscular  tremors  or  spinal  pain  may  be  present.  If  carefully  observed, 
it  is  noticed  that  the  child  develops  slight  paralysis  of  one  or  more  groups 
of  muscles,  but  instead  of  continuing,  the  paralysis  disappears  within  a 
few  hours.  Many  cases,  however,  develop  no  paralysis  at  all.  These  cases, 
nevertheless,  are  believed  to  be  causes  of  infection,  and  it  is  obvious  that 
their  recognition  is  of  extreme  importance  in  controlling  the  spread  of 
the  disease. 

The  diagnosis  of  poliomyelitis,  when  paralysis  is  no  longer  present  or 
has  never  been  present,  may  be  greatly  faciHtated  by  the  examination  of  the 
spinal  fluid  and  by  the  use  of  the  biological  test  for  immunity.  The  spinal 
fluid,  when  examined,  macroscopically,  microscopically,  and  chemically  gives 
helpful  evidence.  The  biological  or  so-called  immunity  test  is  less  practical 
or  reliable,  involving,  as  it  does  considerable  time,  and  the  not  altogether 
constant  performance  of  a  monkey  when  virus,  even  of  high  virulence,  is 
exhibited.  If  the  blood  serum  of  a  true  case  is  mixed  with  virus  of  known 
strength  and  the  combined  material  inoculated  into  a  monkey,  failure  to 
develop  the  disease  in  such  a  monkey  is  considered  presumptive  proof  that 
the  patient's  blood  serum  contained  a  substance  which  neutralized  the  virus 
and  rendered  it  inert.  If,  however,  the  monkey  develops  the  disease,  one 
cannot  positively  conclude  that  the  patient  has  not  or  has  not  had  polio- 
myelitis. Both  the  examination  of  the  spinal  fluid  and  the  "immunity 
test"  leave  much  to  be  desired  in  the  way  of  specificity  and  constancy  of 
results. 


198 

Ordinary  Spinal  Type. 

This  is  the  common  form  of  the  disease  which  has  been  long  known 
and  often  described,  but  a  summary  of  its  principal  features  should  be 
given.  After  an  acute  onset  of  greater  or  less  severity,  motor  paralysis 
appears,  reaching  its  maximum  usually  within  three  or  four  days. 

The  early  symptoms  most  commonly  seen  in  this  type  are  much  the. 
same  in  all  types  of  the  disease,  namely,  fever,  listlessness,  drowsiness, 
sweating,  irregular  breathing,  dyspnoea,  hyperesthesia,  headache,  gastro- 
enteric disturbance.  There  is  often  noticed  a  peculiar  position  of  the 
child  in  bed,  one  of  apparent  great  discomfort.  There  may  be  slight 
rigidity  of  the  neck,  pain  on  forward  traction,  with  slight  Kernig.  There 
may  or  may  not  be  difficulty  of  micturition  or  defecation,  and  sore  throat. 
Muscular  tremors,  irregular  from  fine  to  coarse,  may  be  observed,  especially 
of  the  hands  and  fingers,  but  also  apparent  in  the  entire  extremities ;  weak- 
ness of  the  limbs,  more  particularly  in  the  lower  extremities,  with  early 
diminution  or  loss  of  patellar  reflexes;  and  finally  the  character  of  the 
spinal  fluid  obtained  by  lumbar  puncture,  which,  even  in  the  early  stages 
of  the  disease,  is  usually  characteristic. 

This  fluid,  in  ^  some  cases,  at  the  very  onset  of  the  infection,  has  a 
peculiar  "  ground  glass  "  appearance  (to  be  discussed  later),  while,  in  other 
cases,  it  is  clear  and  has  occasionally  a  yellowish  tint.  Microscopically, 
it  shows  a  predominance  of  mononuclear  lymphocytes.  There  is  an  increase 
in  albumen  and  globulin,  and  Fehling's  solution  is  reduced. 

Later  and  more  definite  symptoms  are :  pronounced  weakness  of  any 
of  the  extremities,  skin  and  muscle  sensitiveness,  spinal  pain,  rigidity  of 
neck  and  back  muscles,  Kernig's  and  MacEwen's  sign.  The  temperature 
ranges  usually  from  102  to  104  or  105°  until  the  paralysis  is  complete, 
when  it  falls  to  normal,  by  lysis,  or,  rarely,  by  crisis.  The  pulse  rate  remains 
high,  noticeably  higher  than  the  temperature  would  indicate.  But  the  flaccid 
motor  paralysis  and  loss  of  reflexes,  may  be  said  to  be  among  the  most 
characteristic  symptoms  of  the  disease. 

The  onset,  in  the  great  majority  of  cases,  is  abrupt,  but  at  times  it 
may  be  insidious  and  the  disease  is  ushered  in  by  somewhat  indefinite 
symptoms  of  an  intestinal  or  anginal  nature.  A  remission  of  from  one 
to  several  days  then  occurs,  to  be  followed  by  a  return  of  all  symptoms  and 
usually  by  an  accompanying  paralysis.  Fever  is  often  the  first  symptom. 
As  a  rule,  there  is  hyperesthesia  or  diffuse  tenderness  over  the  whole  body, 
which  may  persist  from  one  week  to  two  or  three  months.  This  is,  perhaps, 
most  marked  in  the  legs  and  along  the  spine.  Not  infrequently,  the  first 
sign  of  paralysis  in  the  child  is  noticed  by  the  mother  or  nurse,  after  an 
injury,  as  from  falling  from  a  chair  or  when  walking,  etc.,  so  that  a  history 
of  injury  as  the  cause  of  the  affection  may  call  attention  to  the  disease. 

While  paralysis  may,  in  rare  instances,  appear  two  or  three  hours 
after  illness,  clinically  it  is  seldom  possible  to  demonstrate  it  until  three 
or  four  days  later.     A  stationary  period  follows  the  development  of  the 


I 


199 

paralysis,  after  which  begins  a  spontaneous  improvement  in  muscle  power, 
continuing  six  months  or  a  year  longer.  The  final  paralysis,  however,  is 
invariably  less  than  the  initial,  if  the  patient  lives.  The  paralysis  is  more 
often  partial  than  total,  whether  of  an  extremity  or  of  the  whole  body. 
Deformities  occur.  Reflexes  are  diminished,  and  also  sensation  is  affected. 
Disturbances  of  circulation  occur  in  the  severer  cases,  so-called  trophic 
disturbances,  causing  the  paralyzed  part  to  be  usually  cold.  This,  in 
winter,  may  give  considerable  trouble  with  trophic  ulcers,  chilblains,  etc. 

Several  other  types  of  the  disease  have  been  described,  but  one  type, 
clinically,  is  frequently  merged  into  the  other.  The  following  six  additional 
types  described  by  Wickman  may  be  briefly  mentioned,  as  they  belong  to 
the  classics  of  the  literature  of  poliomyelitis. 

Progressive  Type. 
This  type,  in  which  the  paralysis  appears  first  in  the  arms,  extends 
downward  and  finally  upward  to  the  muscles  supplied  by  the  medulla.  When 
the  paralysis  reaches  the  external  muscles  of  respiration  (not  the  centers 
of  respiration  in  the  medulla)  death  is  apt  to  ensue,  and  usually  on  the 
fourth  or  fifth  day.  This  is  the  type  which  probably  was  formerly  described 
under  the  term  "  Landry's  Paralysis  "  and  is  practically  identical  with  it. 

Bulbar  Type. 
This  type,  in  which  the  cranial  nerve  nuclei  are  involved,  the  symptoms 
depending  on  which  of  the  cranial  nerve  nuclei  are  affected,— facial,  abdu- 
cens,  vagus,  etc.  There  may  be  paralysis  of  deglutition  and  the  muscles 
of  the  larynx.  When  the  vagus  is  involved,  there  are  disturbances  of 
respiration  and  of  cardiac  action.  The  respiration  is  at  times  of  the 
Cheyne-Stokes  type.  Involvement  of  one  or  more  of  these  cranial  nerve 
nuclei  is  not  uncommon  in  the  ordinary  spinal  type,  the  resulting  picture 
in  these  cases  being  a  combination  of  the  two,  or  bulbo-spinal  type. 

Acute  Encephalitic  Type, 

This  type,  with  symptoms  resembling  those  of  acute  meningitis :  the 
deep  reflexes,  as  a  rule,  are  exaggerated  and  the  paralysis  is  spastic. 
Diagnosis  is  usually  impossible  without  lumbar  puncture.  This  type  was 
discussed  by  Strumpell,  many  years  ago,  under  the  term  "  acute  encephalitis 
of  children  "  but  it  has  only  recently  been  recognized  as  a  variety  of  polio- 
myelitis. 

Ataxic  Type. 

The  ataxic  type,  of  which  ataxia  is  a  prominent  symptom  in  most  cases. 
In  a  few,  it  is  the  only  nervous  symptom,  and  in  others,  it  is  associated  with 
paralysis  of  the  cranial  nerves  or  spinal  paralysis.  The  ataxia  is  often  of 
the  cerebellar  type. 

Meningitic  Type. 

This  type,  with  symptoms  of  meningeal  irritation,  often  seen  in  the 
early  stages  of  all  types  of  poliomyelitis,  but  at  times  so  marked  that  they 
simulate  those  of  typical  meningitis. 


200 

Polyneuritic  Type. 

The  polyneuritic  type,  in  which  pain  is  often  an  especially  prominent 
syrnptom,  sometimes  located  in  the  joints  but  more  frequently  along  the 
nerve  trunks  or  indefinite  in  its  distribution.  This  symptom  may  be  so 
marked  as  to  cause  the  paralysis  to  be  entirely  overlooked,  the  affection 
being  mistaken  for  rheumatism  or  scurvy.  The  pain  is  usually  most  marked 
in  the  paralyzed  parts,  and  the  effect  produced  is  that  the  extremities  are 
often  held  rigidly  and  all  motion  is  resisted  because  of  the  pain  caused. 
Such  rigidity  and  resistance  is  possible,  of  course,  only  when  the  muscles 
are  partly  paralyzed  or  some  of  them  are  intact,  but  if  the  significance  of 
this  peculiar  combination  of  flaccidity  and  spasticity  is  not  recognized,  it 
may  lead,  in  the  acute  stage,  to  diagnostic  error. 

Aside  from  a  careful  consideration  of  the  general  symptoms  of  the 
infection,  and  laboratory  analysis  of  the  spinal  fluid  on  one  or  more  occasions 
during  the  early  or  febrile  stage  of  the  disease,  nothing  gives  so  accurate  a 
basis  for  diagnosis  as  a  complete  neurological  examination  of  the  patient. 

The  following  is  a  list  of  symptoms  and  objective  signs  in  the  order  of 
their  frequency,  as  noted  at  the  time  of  onset,  in  1,500  cases  studied  with 
particular  care. 

Fever    806 

Nausea  and  vomiting 476 

Malaise  and  weakness   255 

Headache    205 

Constipation   148 

Irritability    '. 125 

Diarrhoea    122 

Coryza    78 

Rigidity  of  neck 74 

Tonsillitis    65 

Pharyngitis 57 

Peripheral  pain   57 

Muscular   twitchings    57 

Prostration   49  , 

Convulsions    47 

Cough    45 

Among  338  cases  at  Queensboro  Hospital,  the  cranial  nerves  were 
involved  in  46  as  follows : 

Optic 2 

Oculomotor    2 

Pathetic    1 

Abducens    12 

Facial   26 

Glossopharyngeal    2 

Hypoglossal 1 

Conjugate  paralysis  of  the  eyes  was  noted  in  2  cases. 


CHAPTER  IX. 

Diagnosis  and  Differential  Diagnosis. 

The  diagnosis  of  poliomyelitis  is  rarely  made  conclusively  before  the 
appearance  of  the  paralysis.  When  the  paralysis  has  occurred,  the  diagnosis 
as-  a  rule  presents  comparatively  little  difficulty,  although  even  when 
paralysis  is  present  the  diagnosis  is  not  always  easy.  Many  cases  are 
undoubtedly  incorrectly  diagnosed  at  the  early  stages  of  the  disease,  even 
when  seen  in  the  midst  of  an  epidemic. 

The  principal  symptoms  which  lead  to  a  diagnosis  of  poliomyelitis 
have  already  been  mentioned.  They  may  be  here  divided  into  subjective 
and  objective  symptoms,  and  laboratory  findings. 

Under  subjective  symptoms  may  be  listed:  those  following  a  history 
of  exposure,  including  vomiting,  pain,  difficulty  in  swallowing,  stiffness 
of  the  neck,  weakness,  and  very  often  intestinal  disturbances  of  some  kind, 
pre-paralytic  and  pre-monitory  diarrhoea,  or  constipation. 

Under  objective  symptoms,  those  most  frequently  to  be  noticed  are: 
fever,  hyperesthesia,  sweating,  nervous  irritability,  stupor,  rigidity,  irregular 
breathing,  dyspnoea,  peculiar  position  of  the  child  in  bed,  regional  pains 
usually  in  the  limbs  aiTected,  motor  paralysis,  or  weakening,  of  erratic 
distribution,  most  marked  in  the  extremities,  especially  the  legs,  and  dimin- 
ution or  loss  of  muscular  or  tendon  reflexes. 

In  doubtful  cases  of  general  infection  presenting  symptoms  referable 
to  the  nervous  system,  particularly  hyperesthesia,  sweating  and  nervDUS 
irritability,  recourse  must  be  had  to  the  examination  of  the  cerebro-spinal 
fluid  by  lumbar  puncture.  This  procedure  is  then  warranted,  and  forms 
our  most  valuable  laboratory  aid  in  the  diagnosis  of  poliomyelitis. 

Differential  Diagnosis. 

In  the  first  twenty-four  to  forty-eight  hours  after  its  onset,  poliomyelitis 
must  be  differentiated  from  the  early  stages  of  epidemic  meningitis  or 
mild  purulent  meningitis,  and  also  from  a  meningism  accompanying  pneu- 
monia or  other  infection. 

The  clinical  pictures  presented  by  the  above  mentioned  diseases  are 
quite  similar,  and  it  is  in  distinguishing  between  them  that  the  examination 
of  the  spinal  fluid  affords  the  most  reliable  information. 

When  seen  a  week  or  more  after  onset,  cases  of  poliomyelitis,  espec- 
ially exhibiting  cerebral  symptoms,  must  be  distinguished  from  tuberculous 
meningitis. 

Though  the  differential  diagnosis  of  selected  cases  of  early  purulent 
meningitis  may  be  fairly  easy,  many  cases  fail  to  follow  the  typical 
description. 


202 

While  epidemics  of  poliomyelitis  usually  occur  in  warm  weather,  and 
epidemics  of  meningitis  in  the  winter  or  spring,  sporadic  cases  of  either 
occur  at  any  time.  A  history  of  gastro-enteritis  or  an  anginal  attack,  three 
to  four  days  prior  to  the  onset,  is  much  more  suggestive  of  poliomyelitis 
than  of  meningitis.  A  history  of  otitis  media,  an  operation  in  the  nose  and 
throat,  or  a  severe  injury  to  the  head,  with  possible  fracture  of  the  skull, 
makes  one  suspect  a  meningitis  due,  most  likely,  to  the  pneumococcus  or 
streptococcus.  The  temperature  of  poliomyelitis  is  usually  higher  at  the 
onset  but  falls  more  quickly  than  in  meningitis.  There  is,  ordinarily, 
greater  hyperesthesia  in  poliomyehtis.  The  reflexes  are  more  apt  to  be 
unequal,  and  the  pupillary  reflexes  are  very  seldom  lost.  In  meningitis, 
there  is  usually  greater  stiffness  of  the  neck,  and  a  more  pronounced 
Kernig.  Delirium  is  much  more  common  than  in  poliomyelitis.  A  hem- 
orrhagic eruption  or  herpes,  if  present,  strongly  suggests  meningitis. 

The  differential  diagnosis  between  poliomyelitis  and  meningism  is  far 
more  difficult,  until  the  underlying  cause  of  the  meningism  develops.  Even 
then  we  may  be  in  doubt  whether  the  pneumonia  or  gastro-enteritis,  etc., 
may  not  be  a  complication  of  the  poliomyelitis. 

In  differentiating  poliomyelitis  and  tuberculous  meningitis,  it  is  to  be 
noted  that  the  onset  is  usually  sudden  in  poliomyelitis  and  gradual  in  tuber- 
culous meningitis,  but  some  few  cases  of  poliomyelitis  give  a  history  of 
gradual  onset,  and  occasionally  tuberculous  meningitis  begins  abruptly. 
In  the  case  of  poliomyelitis  resembling  tuberculous  meningitis,  the  stupor 
is  not  usually  so  profound.  There  is  no  projectile  vomiting,  and  the  pulse 
is  usually  more  regular,  while  the  temperature  declines,  and  the  progress 
of  the  case,  after  the  first  week  or  ten  days,  is  generally  toward  recovery. 
Quite  rarely  in  tuberculous  meningitis,  a  paralysis  may  develop  in  the 
muscles  of  the  eye.  Sometimes  other  paralyses  develop,  as  of  the  face  or 
arms,  but  these  are  usually  transitory. 

In  all  these  conditions,  the  differential  diagnosis  depends  greatly  on 
the  result  of  the  examination  of  the  spinal  fluid,  but  even  here  there  are  no 
pathognomonic  findings.  It  is  by  ruling  out  other  affections  that  it  has 
its  chief  value,  and  it  is  of  service  only  when  correlated  with  a  careful 
clinical  study  of  the  case. 

Findings  in  the  Spinal  Fluid. 
The  spinal  fluid  in  poliomyelitis  is  usually  increased  in  amount  and 
escapes  under  pressure.     It  is  clear  or  slightly  hazy  in  appearance  and 
sometimes  shows  the  fibrin  web  formation,  which  was  formerly  considered 
pathognomonic  of  tuberlous  meningitis. 

Bedside  Tests. 
Recently,  attention  has  been  drawn  to  the  "  ground  glass  "  appearance 
(or  a  slight  haziness  seen  in  the  fluid  when  viewed  by  a  strong  transmitted 
light)  as  being  a  help  in  diagnosing  poliomyelitis.   The  appearance  is  caused 


203 

by  the  increased  number  of  white  blood  cells  (lymphocytes)  which  are 
distinctly  visible  to  the  naked  eye,  but  better  seen  with  the  use  of  a  pocket 
magnifying  lens.  It  is  found  chiefly  in  the  fluids  containing  a  large  number 
of  cells,  and  is  not  so  evident  when  the  cells  are  few  in  number.  The 
increased  number  of  lymphocytes  appear  as  dustlike  particles  uniformly 
suspended  in  the  fluid.  These  particles  can  be  put  into  motion  by  gently 
shaking  the  test  tube  containing  the  fluid.  A  normal  spinal  fluid,  or  a 
poliomyelitis  fluid  which  has  been  standing  for  a  number  of  hours,  and  in 
which  the  cells  have  settled  to  the  bottom,  does  not  exhibit  this  appearance 
unless  the  cells  are  distributed  by  shaking.  It  is  clear  and  limpid,  as  a 
rule.  The  examination  of  the  spinal  fluid  is  best  made  in  a  dark  room  with 
the  test  tube  held  against  an  artificial  light.  This  is  not  as  accurate  a  test 
of  cell  increase  as  the  exact  cell  count,  but  it  is  of  practical  value  as  a  bed- 
side test. 

Any  bedside  test  by  which  cases  of  poliomyelitis  can  be  diagnosed  dur- 
ing the  early  stages  of  the  disease  is  important,  both  for  purposes  of  isola- 
tion and  control  of  infection,  and  for  treatment  of  the  patient.  Several 
precautions,  however,  must  be  observed  in  utilizing  this  test.  First,  there 
must  be  no  red  blood  cells  in  the  spinal  fluid.  Red  blood  cells,  if  only  a  few 
in  number,  can  be  distinguished  macroscopically  by  the  appearance  of  the 
fluid,  and  the  opalescence  produced  by  these  cells  may  be  mistaken  for 
that  caused  by  white  blood  cells.  When  more  numerous,  the  red  blood 
cells  are  recognized  by  a  characteristic  yellowish  shimmer  in  the  fluid.  A 
subsequent  microscopic  examination  should,  at  any  rate,  always  be  made  to 
exclude  the  presence  of  red  blood  cells. 

The  white  blood  cells  (lymphocytes  and  polynuclears)  are  also  found 
increased  in  the  spinal  fluid  in  other  conditions,  especially  tuberculous 
meningitis,  epidemic  cerebro-spinal  meningitis,  syphilitic  involvement  of  the 
meninges  and  vessels  of  the  brain,  etc.  This  macroscopical  ground  glass 
appearance  of  the  spinal  fluid  in  poliomyelitis,  therefore,  cannot  be  said  to 
be  pathognomonic,  but  as  a  bedside  test,  provided  the  precautions  above 
mentioned  are  taken,  it  is  of  diagnostic  value  during  an  epidemic.  The  use 
of  a  miscroscope  at  the  bedside  is  invaluable  for  prompt  diagnosis  of  spinal 
fluids  in  the  field  during  epidemics  of  poliomyelitis. 

In  the  later  stages  of  poliomyelitis,  generally  after  the  seventh  to  the 
tenth  day,  the  cells  in  the  spinal  fluid  rapidly  decrease  in  number  and  soon 
reach  a  normal  count.  In  these  later  stages  of  the  disease  it  is  often  im- 
portant to  establish  a  diagnosis,  especially  where  no  paralytic  symptoms 
have  appeared.  A  simple  and  fairly  accurate  method  of  diagnosing  these 
cases  is  to  remove  the  spinal  fluid  by  lumbar  puncture  and  examine  its 
albimiin  and  globulin  content.  A  majority  of  persons  who  have  had  an 
attack  of  poliomyelitis  will  show  an  increased  amount  of  both  these  sub- 
stances for  a  period  of  eight  to  ten  weeks.  During  an  epidemic,  especially, 
after  a  history  of  some  or  all  of  the  pre-paralytic  symptoms  of  poliomyelitis, 
such  increase  is  strongly  suggestive  of  an  initial  attack. 


204 

The  attached  table  illustrates  rather  strikingly  the  persistence  of  the 
albumin  increase  (the  globulin  content  generally  runs  parallel  with  that  of 
the  albumin),  even  as  late  as  eight  weeks  after  the  onset  of  symptoms. 
It  is  interesting  to  note  that  the  maximum  quantity  of  albumin  is  found  in 
a  larger  proportion  of  cases  during  the  second,  rather  than  the  first  week 
of  the  disease.  In  the  table,  +  +  +  indicates  the  maximum,  ±  the  normal 
amount.  In  this  manner  it  is  often  possible  to  clear  up  the  diagnosis  of 
some  non-paralytic  types  of  poliomyelitis  even  during  the  later  stages  of 
the  disease. 

Albumin  Content  of  Spinal  Fluids  in  Poliomyelitis. 


Days  111. 

Total  No. 
Spinal 
Fluids. 

+  +  + 

% 

+  +  1 
and 

+  + 

% 

+  1 

and 

+ 

% 

± 

% 

1-  7 

7-14 

..          52 
39 

8 

20 

12 

8 

3 

1 
4 
2 

15.4 

51.3 

34.2 

25.8 

11.5 

2.7 

7.8 

4.0 

22 

10 

7 

12 

4 

8 

14 

11 

42.3 
25.6 
20.0 
38.7 
15.4 
21.6 
27.5 
22.0 

18 
6 
11 
7 
14 
18 
20 
26 

34.6 
15.4 
31.4 
22.6 
53.9 
48.7 
39.2 
52.0 

4 
3 
5 
4 
5 
10 
13 
11 

7.7 

7.7 

14-21 

35 

14.3 

21-28 

31 

12   9 

28-35 

35-42 

42-49 

26 

37 
51 

19.2 
27.0 

25  5 

49-56 

50 

22   0 

Total.... 

319    ^ 

+  +  +  Maximum. 
+  +  1 ,  +  +  Large  amount. 
+  1,  +  Moderate  amount. 
=fc  Normal  amount. 

In  addition  to  the  ground-glass  appearance  of  the  fluid,  before  men- 
tioned as  being  of  value  in  the  early  stages,  there  is  another  macroscopic 
test  which  may  be  used  both  early  and  late  in  the  disease.  This  is  the 
so-called  "  foam  test,"  which  depends  upon  the  pathologically  increased 
quantity  of  albumin  and  globulin  in  the  spinal  fluids  of  cases  of  polio- 
myelitis. When  a  test  tube  is  half  filled  with  spinal  fluid  and  throughly 
shaken,  a  persistent  foam  appears  on  the  surface,  which  may  last  from  one- 
half  to  one  hour,  or  longer.  The  foam  thus  produced  in  poliomyelitis  is 
much  denser,  more  voluminous  and  more  peristent  than  that  obtained  with 
normal  spinal  fluid,  but  here  also  the  presence  of  blood  must  be  excluded 
before  making  any  definite  deductions  from  this  test. 

The  needle  best  adapted  for  diagnostic  punctures  has  been  found  to  be 
one  of  No.  18  gauge  and  not  longer  than  three  inches.  Such  a  needle  is 
easily  handled,  does  not  bend,  causes  little  trauma  and  very  little  pain. 
With  the  patient  placed  in  the  proper  recumbent  position  and  the  back  well 
arched,  the  needle  is  introduced  almost  vertically,  but  with  a  slight  upward 
direction,  in  the  median  line  betwen  the  third  and  fourth  lumbar  vertebrae 
on  a  level  with  the  crest  of  the  ileum.  Anaethesia,  local  or  general,  is 
unnecessary  as  a  rule.  But  when  the  child  struggles  considerably,  and  the 
examination  of  the  spinal  fluid  is  of  great  importance  to  clear  up  the 
diagnosis,  a  light  ether  anaesthesia,  for  a  few  minutes,  is  justifiable. 


205 

Laboratory  Examination. 

A  more  complete  examination  of  the  spinal  fluid  must  be  made  in  the 
laboratory,  to  obtain  conclusive  results. 

As  before  alluded  to,  the  spinal  fluid  in  poliomyelitis  shows  evidence 
of  an  inflammatory  reaction ;  there  is  a  varying  increase  in  the  cells  and  in 
the  albumin  and  globulin.  In  some  of  the  cases,  this  evidence  of  inflam- 
matory reaction  is  well  marked;  in  most  cases  it  is  very  moderate,  while 
in  a  few  cases,  at  the  other  extreme,  it  is  so  slight  and  the  fluid  produced 
so  nearly  -  normal,  that  it  is  very  difficult  to  make  a  definite  statement 
regarding  the  findings.  In  these  cases,  laboratory  technique  must  be 
resorted  to,  to  obtain  reliable  results.  The  technique  employed  in  exam- 
ining the  spinal  fluids  in  the  Research  Laboratory  of  the  Department  is 
as  follows : 

All  clear  or  slightly  clouded  fluids  are  centrifuged  at  high  speed  for  an 
hour.  From  the  sediment  spreads  are  made,  taking  care  to  use  as  nearly 
as  possible  the  same  area  on  the  different  slides.  The  sediments  or  clear 
fluids  are  stained  by  the  Ziehl-Nielsen  method  for  the  tubercle  bacillus,  the 
sediment  of  slightly  cloudy  fluids  are  stained  both  for  the  tubercle  bacillus 
and  by  the  Gram  method.  Smears  from  the  poliomyelitis  fluids  are  also 
stained  by  special  blood  stains,  in  order  to  study  the  cells.  From  this  stained 
sediment  we  can  estimate  the  increase  in  cells  as  slight,  moderate,  great,  or 
very  great.  We  can  also  estimate  from  these  stained  sediments  the  per- 
centage of  mononuclear  and  polymorphonuclear  cells  and  note  the  presence 
of  endothelioid  and  polyform  cells.  The  presence  or  absence  of  bacteria 
is  likewise  noted.  Cultures  are  made  from  all  specimens.  Uncontaminated 
poliomyelitis  fluids  have  been  found  uniformly  negative. 

The  chemical  tests  used  are  the  nitric  acid  ring  test  for  albumin,  and 
the  Noguchi  butyric  acid  test  for  globulin.  The  small  amount  of  albumin 
and  globulin  present  in  the  normal  fluids  is  marked,±,  +,  -|-1,  ++,  ++1, 
+++,  etc.,  representing  increasing  amounts,  and  serves  as  a  rough  quan- 
titative estimation  of  the  albumin  and  globulin.  The  presence  of  glucose  is 
tested  by  using  an  equal  amount  of  Fehling's  solution  and  spinal  fluid,  and 
it  is  marked  according  to  the  speed  and  the  amount  of  reduction  as  — , 
=!=,  -{-,  -f+,  +++.  The  globulin  reaction  and  reduction  of  Fehling's  solution 
should  not  be  read  for  at  least  half  an  hour. 

Taking  up  these  points  more  in  detail,  the  cytology  must  first  be  con- 
sidered. The  increase  in  cells  varies  greatly,  both  in  different  cases  and 
in  the  stage  at  which  the  puncture  is  made.  Our  counts  have  varied  from 
slightly  above  normal,  that  is,  from  15  to  20,  to  1,000  or  more.  The  counts 
tend  to  fall  off  after  the  first  week  and  by  the  end  of  the  second  week  have 
dropped  to  practically  normal,  in  nearly  all  instances. 

The  cells  usually  show  a  preponderance  of  mononuclears,  but,  in  a  few 
cases  there  are  over  fifty  per  cent,  of  polymorphonuclears.  It  has  been 
stated  by  some  that  early  in  the  disease  there  is  an  excess  of  polymor- 


206 

phonuclears,  which  later  are  replaced  by  mononuclears.  We  found,  in  an 
examination  of  1,500  fluids,  many  of  which  were  taken  in  the  2nd,  3rd  and 
4th  days  of  the  disease,  that  the  polynuclears  predominated  only  in  39  cases, 
in  these  instances  the  fluids  being  collected  on  days  of  the  disease  from 
2nd  to  27th.  The  polymorphonuclears,  therefore,  in  our  opinion,  represent 
a  definite  type  of  reaction,  not  a  stage  of  the  disease.  Often,  even  in  the 
fresh  fluids,  the  cells  are  so  degenerated  that  it  is  difficult  to  classify  them. 
There  have  been  found  large  mononuclear  cells  apparently  endothelioid  in 
type  that  seem  to  occur  more  frequently  in  poliomyelitis  than  in  other  con- 
ditions.   The  so-called  polyform  cells  are  also  found. 

Albumin  and  globulin,  as  before  stated,  are  usually  increased  slightly 
to  moderately.  Fehling's  solution  is  practically  always  well  reduced.  The 
fluids  that  show  a  poorer  reduction  are  usually  those  with  the  larger 
amount  of  albumin  and  globulin. 

Differential  Diagnosis  of  Spinal  Fluids. 

Slightly  cloudy  fluids  in  poliomyelitis  must  be  differentiated  from  those 
in  early  cases  of  purulent  meningitis,  and  from  the  slightly  cloudy  fluid  that 
occasionally  occur?  in  tuberculous  meningitis.  The  clear  or  practically  clear 
fluids  must  be  distinguished  from  rare  early  cases  of  purulent  meningitis, 
tuberculous  meningitis,  syphilis  of  the  central  nervous  system,  especially 
acute  syphilitic  meningitis,  and  meningism.  Other  rarer  conditions  might  be 
mentioned,  but  these  are  the  most  important. 

In  the  early  cases  of  purulent  meningitis,  the  spinal  fluid  shows  a  vary- 
ing degree  of  cloudiness,  except  in  very  rare  instances,  when  it  may  be 
clear.  A  greater  increase  in  albumin  and  globulin  is  usually  found  here 
than  occurs  in  poliomyelitis,  with  a  poorer  reduction  of  Fehling  solution. 
The  cells,  in  these  fluids  of  purulent  meningitis,  are  ninety  per  cent,  or 
more  polynuclears,  and  the  etiological  organism  is  always  found,  except  in 
the  mildest  cases.  In  certain  mild  cases  of  meningitis,  probably  of  the 
epidemic  variety,  the  meningococci  may  never  be  positively  demonstrated 
in  the  fluid.  In  purulent  meningitis,  due  to  other  organisms,  these  prac- 
tically always  appear  later.  In  one  instance  only  have  we  seen  a  clear 
fluid  from  an  early  case  of  epidemic  meningitis  of  about  eighteen  hours' 
duration.  Although  the  cellular  reaction  was  so  slight,  the  meningococcus 
was  demonstrated  to  be  present  in  the  fluid  by  smear  and  culture. 

The  fluid  in  tuberculous  meningitis  most  nearly  resembles  that  of 
poliomyelitis.  It  is  practically  always  clear,  with  a  cellular  increase  con- 
sisting largely  of  mononuclears,  though  in  very  acute  cases  the  fluid  may 
be  distinctly  cloudy  with  an  excess  of  polymorphonuclears.  Fortunately, 
in  these  cases,  the  tubercle  bacillus  is  usually  easy  to  demonstrate.  The 
number  of  cells,  per  cubic  millimeter,  is  usually  greater  than  in  polio- 
myelitis; the  increase  in  albumin  and  globulin  is  more  marked,  and  the 
reduction  of  Fehling's  solution  is  not  so  great. 


207 

In  rare  instances,  when  clinical  signs  are  confusing,  when  the  results 
of  the  cellular  examination  and  chemical  analysis  are  indefinite,  and  it  is 
impossible  to  demonstrate  tubercle  bacillus  in  the  fluid,  a  positive  diagnosis 
must  wait  upon  the  results  of  animal  inoculation. 

The  fluid  of  an  acute  syphilitic  meningitis  closely  resembles  the  fluid 
of  poliomyelitis,  and  the  clinical  signs  are  also  confusing.  The  Wassermann 
reaction  is  the  best  method  of  differentiating  the  two  conditions.  Of  course, 
a  positive  Wassermann  would  not  rule  out  a  poliomyelitis  in  an  old  syphilitic 
condition,  but  this,  combined  with  the  clinical  conditions  and  the  progress 
of  the  case,  makes  one  reasonably  sure  of  the  diagnosis.  It  was  suggested 
at  first  that  the  products  of  degeneration  present  in  the  spinal  fluid  of 
poliomyelitis  cases  might  give  a  non-specific  Wassermann  reaction.  Tests, 
in  about  three  hundred  and  fifty  cases,  have  proved  this  not  to  be  true. 

The  fluid  of  meningism  is  clear,  increased  in  amount,  and  practically 
always  normal  in  character.  The  few  exceptions  to  this,  found  in  exam- 
ining a  large  number  of  cases,  have  fallen  commonly  into  three  groups : 
fluids  from  cases  with  prolonged  and  severe  convulsions ;  fluids  in  severe 
whooping  cough;  and  fluids  removed  just  prior  to  death.  In  these  cases 
there  has  sometimes  occurred  an  increase  in  cells,  or  in  globulin  or  albumin, 
or  both.  In  convulsions  there  is  probably  edema,  in  whooping  cough, 
minute  hemorrhages,  and  just  before  death,  circulatory  changes  to  account 
for  it. 

Two  rare  types  of  spinal  fluids  sometimes  occur  in  poliomyelitis, 
when  the  hemorrhagic  process  has  been  more  than  usually  severe.  The 
first  of  these  is  of  the  true  hemorrhagic  character,  the  red  blood  cells 
being  evenly  diffused  throughout  the  fluid.  When  collected  in  successive 
tubes,  the  specimens  are  all  homogeneous,  showing  no  change  in  the  intensity 
of  the  hemorrhage.  This  serves  to  differentiate  it  from  bloody  fluids 
obtained  by  the  accidental  puncture  of  a  vein.  Evidence  of  an  older  hem- 
orrhagic condition  occurs  in  the  second  of  these  rarer  fluids,  which  having 
a  characteristic  yellow  color  and  coagulating  spontaneously,  illustrates  the 
so-called  syndrome  of  Froin.  These  fluids  occur  in  other  conditions  and 
are  therefore  not  pathognomonic  of  poliomyelitis. 

Two  thousand  poliomyelitis  fluids  were  examined  at  the  Research 
Laboratory  of  the  Department,  but  only  five  hundred  of  these  were  care- 
fully studied.  Statisticians  state  that  results  based  on  five  hundred  speci- 
mens, and  results  based  on  two  thousand  or  more,  would,  to  all  intents  and 
purposes,  be  the  same.  It  seemed  better,  therefore,  to  take  this  smaller 
number  and  make  careful  studies  of  them,  rather  than  to  attempt  to  use 
a  larger  number  of  specimens  and  study  the  data  less  thoroughly. 

Tables  on  pages  228-231  inclusive,  show  the  findings  obtained  in  the 
laboratory  examination  of  spinal  fluids  in  poliomyelitis  cases. 


208 

Colloidal  Gold  Test. 

Lange's  Colloidal  Gold  Test,*  in  the  hands  of  some  of  our  workers,  has 
been  helpful  in  differentiating  the  fluids  of  poliomyelitis  from  those  of 
tuberculous  meningitis,  and  from  the  fluids  of  meningism,  which  are  not 
normal  in  character.    This  test  is  as  follows : 

Into  the  first  of  eleven  test  tubes  put  0.9  c.  c.  of  fresh,  sterile  0.4%  NaCl 
solution.  Into  each  of  remaining  tubes  put  0.5  c.  c.  of  the  0.4%  NaCl 
solution.  Add  to  the  first  tube  0.1  c.  c.  of  the  spinal  fluid  to  be  tested. 
Mix  well. 

Transfer  0.5  c.  c.  of  the  resultant  1  to  10  dilution  of  spinal  fluid  to 
the  second  tube.    Mix  well. 

Transfer  0.5  c.  c.  of  the  resultant  1  to  20  dilution  of  spinal  fluid  to  the 
third  tube.    Mix  well. 

Proceed  in  this  manner  up  to  and  including  the  eleventh  tube. 

By  this  method  a  series  of  dilutions  of  spinal  fluid  is  secured,  in 
geometrical  progression,  ranging  from  1  to  10,  to  1  to  5,120. 

Now  add  to  each  tube  2^/2  c.  c.  of  Colloidal  Gold  solution. 

Shake  each  tube  thoroughly  and  do  not  read  for  12  hours. 

The  various-  types  of  color  changes  seen  in  the  positive  gold  reaction 
are  indicated  by  numerals  as  follows : 

Complete  decolorization   5 

Pale  blue    4 

Blue 3 

Lilac  or  purple 2 

Red-blue    1 

Brilliant  red-orange — normal  color 0 

A  normal  fluid  would  remain  brilliant  red-orange  color  and  would, 
therefore,  read  00000000000  or  a  very  slight  reaction  11100000000. 

A  poliomyelitis  fluid  (as  found  in  78  cases  of  positive  poliomyelitis) 
would  remain  brilliant  red-orange  color  in  the  first  two  tubes,  slightly  bluish 
in  third,  purple  in  fourth  tube  and  again  bluish  in  fifth,  returning  to  normal 

*Note — Zsigmondy  following  an  exhaustive  study  of  the  subject  of  the  "coagu- 
lating" action  of  electrolytes,  or  metallic  colloidal  solution,  was  able  to  find  a 
definite  measure  of  the  protective  action  of  certain  colloids,  especially  proteins,  on 
the  precipitation  of  gold  suspensions  by  sodium  chloride.  The  degree  of  protection 
was  specific  for  each  protein  he  examined.  By  using  this  general  method  he  was 
enabled  to  distinguish  between  luetic  and  normal  sera.  Lange  proceeded  further,  and 
found  that  normal  spinal  fluids,  suitably  diluted  with  a  four  per  cent,  soilution  of 
sodium  chloride,  caused  no  alkalination  in  suitable  solutions  of  colloidal  gold,  and 
abnormal  spinal  fluids  caused  partial  or  complete  precipitation  of  colloidal  gold  with 
resultant  color  changes  occurring  in  curves,  which  tend  to  be  almost  specific  for 
certain  diseases,  particularly  those  of  luetic  origin.  This  specificity  is  characterized 
by  maximal  color  changes  within  dilution  zones.  Fluids  from  different  types  of  menin- 
gitis give  reactions  with  greatest  intensity  in  higher  dilutions.  Paretic  fluids  cause 
complete  flocculation  in  the  first  four  to  six  dilutions.  Tabes  and  cerebro-spinal  lues 
giye  maximal  reactions  in  fourth  to  fifth  dilutions.  We  have  Lange's  results  in  105 
fluids.  Lange's  results  agree  with  our  clinical  and  laboratory  diagnoses  in  103  cases. — 
Bui.  Johns  Hopkins  Hospital,  XXVI,  No.  298. 


209 

red-orange  in  sixth  tube,  and  would,  therefore,  read  approximately 
00123000000. 

Two  hundred  positive  poliomyelitis  fluids  tested  by  the  Lange  gold 
reaction  in  the  State  Department  of  Health  showed  the  following  values : 
11122110000,  and  there  were  readings  varying  all  the  way  from  11110000000 
to  12321000000. 

In  other  words,  the  readings  given  cannot  be  considered  absolute,  and 
the  emphasis  may  shift  to  the  right  or  left,  within  moderate  limits,  but  in 
the  main  the  usual  reading  corresponds  with  the  readings  in  a  weak  luetic 
spinal  fluid. 

A  meningitis  fluid  unchanged  in  first  two  tubes  and  ranging  from  this 
to  colorless  in  the  ninth  tube  and  back  to  original  in  the  eleventh  tube, 
approximately  00112234531. 

Curves  showing  these  typical  reactions  and  readings  are  given  on  pages 
211  and  213. 

Curve  I  shows  the  result  obtained  in  Paretic,  Meningitic  and  Luetic 
spinal  fluids. 

Curves  II  and  VII  show  various  poliomyelitis  readings. 

Chart  VIII  is  the  composite  of  II  to  VII,  giving  the  average  curve  fol 
90  fluids. 

Quantitative  Chemical  Studies  in  Spinal  Fluids. 

Quantitative  studies  in  spinal  fluids  of  poliomyelitis  and  various  forms 
of  meningitis  have  been  undertaken  in  the  Research  Laboratory,  with  the 
hope  that  these  studies  would  throw  some  light  either  on  the  diagnosis  or 
prognosis  of  these  diseases.  The  determinations  attempted  embrace  total 
non-protein,  urea  and  ammonia  nitrogen,  uric  acid,  creatinine,  creatine, 
sugar  and  cholesterol.  The  methods  employed  were  adaptations,  and  in 
some  cases,  modifications  of  the  micro-chemical  procedures  so  extensively 
used  in  blood  investigations. 

Only  blood-free  fluids  were  used  in  these  determinations.  It  might  be 
said,  however,  that  water  clear  spinal  fluids  which,  on  centrifuging,  show 
a  fine  grayish-white  sediment  appearing  to  be  totally  free  from  blood, 
occasionally  on  microscopic  count  show  the  presence  of  several  red  cells 
per  c.  c.  It  seems  to  be  impossible  to  pass  through  the  skin  and  sub- 
cutaneous tissues  in  a  lumbar  puncture  without  taking  up  a  few  red  cells, 
and  these  appear  to  be  insignificant  so  far  as  the  chemical  determinations 
are  concerned. 

With  the  exception  of  urea,  which  has  been  extensively  studied  by 
French  workers  (i),  quantitative  studies  in  spinal  fluids  are  comparatively 
meager,  due  undoubtedly  to  the  fact  that  until  recently,  micro-methods  not 
being  available  for  these  determinations,  any  single  chemical  test  required 
relatively  large  quantities  of  spinal  fluid  and  this  was  not  often  available. 


(1)   Soper  and  Granat,  Arch.  Int.  Med.,  XIII,  131,  1914,  review  the  literature. 


210 

According  to  Plaut,  Rehm  and  Schottmiiller,  (2)  normal  spinal  fluid 
contains  from  30  to  60  mgm.  of  protein  per  100  c.  c.  These  figures  are 
increased  in  various  diseases  extending  in  meningitis  as  high  as  250  mgm. 
per  100  c.  c.  More  recent  workers  (^)  report  in  syphilitic  and  other  patho- 
logical conditions  quantities  of  protein  extending  from  20  to  100  mgm.  per 
100  c.  c.  of  fluid.  Total  nitrogen  in  spinal  fluids  ranges,  according  to 
Rosenbloom,(^)  from  162  to  362  mgm.  per  100  c.  c.  Woods (^)  finds  the 
non-protein  nitrogen  in  spinal  fluid  about  25  per  cent,  less  than  that  found 
in  the  blood,  i.  e.,  about  20  mgm.  per  100  c.  c.  of  fluid.  This  is  in  agreement 
with  that  reported  by  other  workers (^).  The  concentration  of  urea  in  this 
fluid,  on  the  other  hand,  appears  to  be  equal  to  that  of  the  blood (''').  In 
nephritis.  Fine  and  Myers (^)  found  that  the  concentration  of  creatinine  in 
spinal  fluid  is  46  per  cent,  of  that  in  the  blood ;  of  creatine,  22  per  cent,  and 
of  uric  acid,  5  per  cent  of  the  respective  concentrations  of  the  blood. 

Schloss  and  Schroeder(^)  recently  studied  the  sugar  content  in  spinal 
fluids  of  infants  and  children,  and  found  that  in  cases  free  from  meningeal 
diseases  the  sugar  ranged  from  .05  to  .134  per  cent.  In  cases  of  meningitis 
these  figures  were  considerably  decreased.  The  presence  of  cholesterol  in 
spinal  fluids  has  been  reported  by  various  workers  (^^)  in  different  forms  of 
paralysis. 

Total  Nitrogen. 

The  method  employed  for  the  determination  of  total  nitrogen  in  spinal 
fluids  was  a  modification  of  the  direct  Nesslerization  method  recently 
developed  by  Folin  and  Denis (^i).  The  modification  in  detail  is  presented 
in  another  place(i2)_  j^  this  connection,  only  a  brief  outline  of  the  pro- 
cedure will  be  given. 

Two  c.c.  of  spinal  fluid  are  pipetted  into  a  test  tube,  1  c.c.  of 
the  concentrated  acid  mixture  (containing  1  volume  concentrated 
sulphuric  acid,  3  volumes  concentrated  phosphoric  acid  and  one 
fifteenth  volume  of  a  10  per  cent,  solution  of  copper  sulphate)  added 
and  the  digestion  carried  out  over  a  micro-burner  until  the  appear- 
ance of  white  sulphuric  acid  fumes  ;  the  mouth  of  the  test  tube  is 
then  covered  with  a  watch  glass  and  heating  continued  for  about  a 
minute.  The  color  obtained  is  usually  straw  yellow.  After  permit- 
ting the  test  tube  to  cool,  the  contents  are  rinsed  quantitatively  into 
a  100  c.c.  volumetric  flask,  using  about  60  c.c.  of  water  in  the  process. 
A  quantity  of  10  per  cent,  sodium  hydroxide  is  then  added,  sufficient 


(2)  Leitfaden  zur  Untersuchung  der  Zerebrospinal  fliissigkeit,  Jena.  1913,  p.  16. 

(3)  Pfeiffer,  Kober,  and  Field,  Proceed.  Soc.  Exp.  Biol,  and  Med.,  XII,  153,  1915. 

(4)  Rosenbloom,  Biochemical  Bulletin,  V.  24,  1916. 

(5)  Woods,  Arch.  Int.  Med.,  XVI,  577,  1915. 

(6)  Millard  and  Proment,  Journ.  de  Physiol  et  de  Path.  General,  XI,  263,  1909. 

(7)  Cullen  and  Ellis,  Journ.  Boil.  Chem.  XX,  511,  1915. 

(8)  Fine  and  Myers,  Proceedings  Society  for  Exp.  Biol,  and  Med.,  XIII,  70,  1916. 

(9)  Schloss  and  Schroeder,  Amer.  Jour.  Dis.  of  Child.,  XI,  1,  1916. 

(10)  Pithini,  Zeitsch.  f.  Phys.  Chem.,  61,  508,  1909. 

(11)  Folin  and  Denis,  Journ.  Biol.  Chem.,  XXVI,  473,  1916. 

(12)  Kahn,  Journ.  Biol.  Chem.,  XXVIII,  203,  1916. 


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Poliomyelitis 

Normal  Finding 


215 

to  neutralize  the  c.c.  of  concentrated  acid  and  permit  a  surplus  of 
2  c.c.  of  alkali.  Then  water  is  added  to  make  up  to  volume,  and  the 
mixture  is  filtered.  Into  another  100  c.c.  volumetric  flask  are 
pipetted  1  c.c.  of  the  concentrated  acid  mixture,  diluted,  20  c.c. 
of  the  standard  ammonium  sulphate  solution  containing  1  mgm. 
ammonia  nitrogen  and  an  amount  of  10  per  cent,  alkali  solution  equal 
to  that  added  to  the  unknown.  This  is  also  made  up  to  volume, 
shaken  and  filtered. 

Aliquot  portions  of  these  filtrates  are  employed  for  Xessleriza- 
tion.  Thus  50  c.c.  of  the  water-clear  filtrates  of  both  the  unknown 
and  standard  are  pipetted  into  two  100  c.c.  volumetric  flasks,  diluted 
to  about  75  c.c.  with  water,  10  c.c.  of  Nessler  solution  added  to  each, 
made  up  to  volume,  shaken,  and  the  colors  compared  on  the  colori- 
meter. The  same  results  should  be  obtained  by  using  50  c.c.  volu- 
metric flasks  and  employing  25  c.c.  quantities  of  respective  filtrates 
for  Nesslerization. 

The  total  nitrogen  in  poliomyelitis  appears  to  be  in  the  neighborhood 
of  25  mgm.  per  100  c.c.  of  spinal  fluid.  In  various  forms  of  meningitis, 
the  total  nitrogen  was  found  to  be  considerably  increased,  extending  from 
35  mgm.  to  about  150  mgm.  per  100  c.c.  Total  nitrogen  determination 
alone,  however,  are  of  comparatively  little  value,  on  account  of  the  variations 
of  the  non-protein  nitogen  content.  This  is  perhaps  well  to  emphasize, 
in  view  of  the  attempt  of  Landau  and  Halpern(i^)  to  show  that  a  certain 
antagonism  exists  between  total  nitrogen  and  chlorides  in  spinal  fluid;  that 
a  high  finding  of  the  one  corresponds  to  a  low  finding  of  the  other.  A  high 
total  nitrogen  may  often  be  due  to  an  increase  in  the  non-protein  nitrogen, 
particularly  in  the  presence  of  kidney  disturbances. 

Non-Protein  Nitrogen,  Procedure:  To  5  c.c.  of  spinal  fluid  in 
a  large  test  tube  are  added  quantitatively  2  c.c.  of  a  freshly  prepared 
25  per  cent,  solution  of  glacial  phosphoric  acid.  The  test  tube  is  then 
stoppered,  shaken  and  permitted  to  stand  one  to  twenty-four  hours 
and  filtered  through  a  small,  dry  filter  paper.  Either  5  or  3  c.c.  quan- 
tities of  the  ^^'ater-clear  filtrates  are  used  for  a  nitrogen  determina- 
tion, the  procedure  being  identical  with  that  described  for  total 
nitrogen. 

Urea  Nitrogen,  Procednrei^^) :  To  5  c.c.  of  spinal  fluid  in  a 
100  c.c.  volumetric  flask  are  added  about  5  c.c.  of  water  and  0.1  gm. 
of  dry  urease,  shaken  and  permitted  to  stand  at  room  temperature 
from  fifteen  to  twenty  minutes.  This  is  then  diluted  with  about 
50  c.c.  of  water,  2  c.c.  of  freshly  prepared  glacial  phosphoric  acid 
added,  also  0.5  gm.  of  IMerck's  charcoal  and  made  up  to  volume. 
This  is  shaken  from,  time  to  time  and  allcnved  to  stand  for  forty-five 
minutes  or  more,  when  it  is  ready  to  be  filtered.  Definite  portions  of 
the  water-clear  filtrates  are  used  for  Nesslerization  as  in  the  cases 
of  the  total  and  non-protein  nitrogen  determinations. 

The  non-protein  nitrogen  content  in  spinal  fluid  is  about  50  to  70  per 
cent,  of  the  total  nitrogen,  and  urea  about  60  to  80  per  cent,  of  the  non- 
protein nitrogen. 

(13)  Landau  and  Halpern,  Biochem.  Zeitsch.,  IX,  72.  1908. 

(14)  Folin  and  Denis,  Journ.  Biol.  Chem.,  XXVI,  505,  1916. 


216 

Ammonia  Nitrogen. 

The  determinations  of  ammonia  were  unsatisfactory,  because  suffi- 
ciently large  quantities  of  a  single  fluid  required  for  a  test  were  not  available. 
Mixed  fluids,  therefore,  had  to  be  resorted  to.  This  procedure  seemed 
justifiable,  in  view  of  the  fact  that  Frankel-Heiden(i^)  was  unable  to 
demonstrate  ammonia  in  spinal  fluids.  The  findings  show  wide  variations, 
with  figures  ranging  from  0.1  mgm.  to  9.0  mgm.  of  ammonia  nitrogen  per 
100  c.c.  of  spinal  fluid.  It  might  be  said  also  that  these  fluids,  although 
sterile  at  the  time  of  the  determinations,  had  been  kept  in  the  ice  box  for 
several  weeks,  which  might  slightly  affect  the  results. 

Procedure:  To  25  c.c.  spinal  fluid  were  added  3  c.c.  of  glacial 
phosphoric  acid,  mixed,  allowed  to  stand  about  an  hour  and  filtered; 
25  c.c.  of  the  filtrate  were  pipetted  into  a  50  c.c.  volumetric  flask, 
5  c.c.  Nessler  solution  added,  made  up  to  volume  and  compared  with 
a  standard  of  ammonium  sulphate  solution  containing  0.25  mgm. 
nitrogen  in  100  c.c. 

Uric  Acid. 

The  determinations  of  uric  acid  also  were  carried  out  on  mixed  fluids. 
Twenty-five  c.c.  quantities  of  mixed  water  clear  sterile  fluids  were  used 
for  a  test.  The" Benedict (^'^)  modification  of  the  Folin  and  Denis(i^) 
method  was  employed.  The  results  indicate  that  there  are  present  from 
0.25  mgm.  to  0.5  mgm.  of  uric  acid  per  100  c.c.  spinal  fluid. 

Procedure:  25  c.c.  spinal  fluid  were  added  to  boiling  0.01  normal 
ascetic  acid  in  a  casserole;  boiling  continued  for  about  a  minute; 
removed  from  the  flame,  about  200  c.c.  of  bailing  water  added  and 
poured  over  a  folded  filter.  Filtrate  was  then  concentrated  to  about 
50  c.c,  cooled,  and  about  0.5  c.c.  of  dialized  iron  added  drop  by  drop, 
shaking  with  each  addition.  Filtered  and  water-clear  filtrate  was 
concentrated  to  about  2.3  c.c.  transferred  quantitatively  to  a  centri- 
fuge tube,  using  about  5  c.c.  of  hot  water  to  wash  out  the  vessel.  To 
the  solution  in  the  centrifuge  tube  was  now  added  about  15  drops 
of  ammonia  silver  magnesia  mixture,  allowed  to  stand  for  about  ten 
minutes  to  permit  precipitatio'n,  when  it  was  centrifuged  at  a  high 
speed  for  about  5  minutes.  The  supernatant  fluid  was  poured  off 
and  excess  of  ammonia  drawn  off  by  inverting  the  tube  on  filter 
paper.  Two  drops  of  a  5  per  cent,  solution  of  KCN  are  added  to 
dissolve  the  precipitate,  also  1  c.c.  of  the  phasphotungstic  acid  reagent 
and  about  8  c.c.  of  saturated  solution  of  sodium  carbonate.  This  is 
permitted  to  stand  for  a  minute,  transferred  into  a  25  c.c.  or  50  c.c, 
volumetric  flask,  depending  on  the  intensity  of  the  color,  made  up  to 
volume  with  water  and  compared  with  the  standard  on  the  Dubosque 
colorimeter.  The  latter  is  prepared  by  pipetting  5  c.c.  of  the  uric 
acid  standard  solution  containing  KCN,  2  c.c.  of  phosphotungstic 
acid  reagent  and  15  c.c.  of  saturated  sodium  carbonate  added  and 
made  up  to  the  mark  with  water. 


(15)  Frankel-Heiden,   Biochem.   Zeitsch.,   11,   188,   1906-1907. 

(16)  Benedict,  Journ.  Biol.  Chem.,  XX,  629,  1915. 

(17)  Folin  and  Denis,  Journ.  Biol.  Chem.,  XIII,  469,  1912-13. 


217 

Creatinine  and  Creatine. 

For  the  determinations  of  creatinine  and  creatines,  the  FoHn  and 
Denis  (1^)  methods  were  employed.  These  methods  have  been  recently 
criticised  by  McCrudden  and  Sargent (i").  The  results,  nevertheless,  seem 
worth  reporting,  in  view  of  the  creatinine  and  creatine  studies  on  blood  with 
the  same  methods.  In  poliomyelitis  the  spinal  fluids  were  found  to  contain 
about  0.5  mgm.  of  creatinine  per  100  c.c.  and  somewhat  less  than  this 
amount  of  creatine.  The  recent  conclusions  of  Gettler  and  Baker (^o)  that 
normal  blood  contains  no  more  than  0.5  mgm.  creatinine  per  100  c.c.  is 
of  interest  in  this  connection.  If  the  method  of  Folin  and  Denis  be  correct, 
then  it  is  likely  that,  similar  to  urea(2i),  creatinine  also  is  equally  dis- 
tributed in  the  blood  and  spinal  fluid. 

Procedure:  To  5  c.c.  of  spinal  fluid  were  added  20  c.c.  of  sat- 
urated solution  picric  acid,  filtered,  and  10  c.c.  quantities  of  the  fil- 
trate were  employed  for  creatinine  and  creatine  determinations, 
respectively.  The  standards  employed  were  solutions  of  crea- 
tinine (^2)  in  saturated  picric  acid.  The  color  was  developed  by 
adding  0.5  c.c.  of  10  per  cent,  sodium  hydroxide  solution  and  allowing 
to  stand  ten  minutes.  Several  standards  were  prepared  and  the  color 
of  the  unknown  matched  with  the  one  which  approached  it  closest  in 
intensity.  In  the  case  of  the  creatine  determinations,  the  standard 
also'  was  autoclaved.  This,  it  is  believed,  reduced  the  chances  of 
error  considerably. 


Sugar. 

Sugar  was  determined  by  means  of  the  Lewis  and  Benedict (^s)  method, 
slightly  modified.  The  findings  in  poliomyelitis  are  at  a  somewhat  lower 
level  than  that  of  the  blood — about  0.06  per  cent.  In  meningitis  only  traces 
were  found  in  most  cases. 

Procedure:  Four  volumes  of  saturated  solution  of  picric  acid 
were  added  to  1  volume  of  spinal  fluid,  shaken  and  filtered.  To 
3  c.c.  of  the  filtrate  in  a  test  tube  graduated  to  the  10  c.c.  mark  is 
added  1  c.c.  of  saturated  solution  sodium  carbonate  and  placed  in 
boiling  water  for  about  twenty  minutes,  after  which  it  is  cooled  and 
made  up  to  10  c.c.  with  water.  The  standard  employed  is  a  solution 
of  glucose  (Kahlbaum)  in  saturated  picric  acid.  To  3  c.c.  of  this 
solution  containing  0.5  mgm.  of  glucose  is  added  1  c.c.  of  saturated 
sodium  carbonate  solution,  kept  in  a  water  bath  for  about  twenty 
minutes,  cooled,  made  up  to  10  c.c.  and  compared  on  the  colorimeter 
with  the  unknown. 


(18)  Folin  &  Denis,  Jou'I  Biol.  Chem.,  XVIII.  475,  1914. 

(19)  McCrudden  and  Sargent,  Journ.  Biol.  Chem.,  XXVI,  527,  1916. 

(20)  Gettler  and  Baker,  Journ.  Biol.  Chem.,  XXV,  211,  1916. 

(21)  Cullen  and  Ellis,  loc.  cit. 

(22)  Kindly  furnished  by  Dr.  A.  O.  Gettler  of  the  Bellevue  Chem.  Labs. 

(23)  Lewis  and  Benedict,  Journ.  Biol.  Chem.,  XX,  61,  1915. 

(24)  Compare  Myers  and  Bailey,  Journ.  Biol.  Chem.,  XXIV,  147,  1916. 


218 

Cholesterol. 

-  An  attempt  was  made  to  determine  cholesterol  in  spinal  fluids  by  the 
method  recently  suggested  by  Bloor(25).  In  no  case,  however,  were  the 
amounts  sufficient  for  quantitative  determinations.  All  fluids  tested  showed 
the  presence  of  traces  only. 

Chart  I. — Shows  the  findings   in  cases  of  poliomyelitis.     Suc- 
cessive fluids  from  the  same  case  are  indicated  by  a,  b,  c,  etc.     Ap- 
"  ■•         pended  is  a  chart  showing  the  findings  in  successive  punctures. 
i  Chart  II. — Shows  cases  of  purulent  meningitis,  meningococcic, 

streptococcic  and  influenzal.     Appended  is  a  chart  showing  the  find- 
ings in  successive  punctures. 

Chart  III. — Shows  cases  of  tuberculous  meningitis  with  the  find- 
ings in  successive  punctures. 

Chart  IV. — Shows  miscellaneous  fluids. 
"  Chart  V. — Curves  showing  the  percentage  of  non-protein  nitrogen 
in  the  total  nitrogen. 

Chart  VI. — Curve  showing  the  percentage  of  urea  nitrogen  in 
total  nitrogen. 

Chart  VII. — Curve  showing  thef  percentage  of  urea  nitrogen  in 
non-protein  nitrogen. 

Chart  VIII. — Showing  the  medium  of  the  total  nitrogen,  non- 
protein nitrogen,  urea  nitrogen,  creatine,  creatinine  and  sugar  in  the 
various  diseases.  The  medium  is  used  instead  of  the  average,  as  it 
is  the  truer  index  of  the  greater  incidence  of  values.  It  is  obvious 
in  estimating  averages  that  a  very  few  high  or  very  low  determina- 
tions will  unduly  influence  the  result. 


Poliomyelitis  Fluids  Tested. 

Seventy-four  poliomyelitis  fluids  were  tested  for  six  substances : 
Total  nitrogen,  non-protein  nitrogen,  urea  nitrogen,  creatinine,  creatine 
and  sugar. 

The  total  nitrogen  in  24  of  these  fluids  varied  from  16.37  to  34.00  in  mgms.  per  100  c.c. 
The  non-protein  nitrogen  in  16  of  these  fluids  varied  from  12.08  to  24.78  in  mgms. 

per  100  c.c.     , 
The  urea  nitrogen  in  17  of  these  fluids  varied  from  5.06  to  26.6  in  mgms.  per  100  c.c. 
The  creatinine  in  22  of  these  fluids  varied  from  0.273  to  0.56  in  mgms.  per  100  c.c. 
The  creatine  in  11  of  these  fluids  varied  from  0.190  to  0.49  in  mgms.  per  100  c.c. 
The  sugar  in  36  of  these  fluids  varied  from  0.025  to  1.00  in  mgms.  per  100  c.c. 

The  outcome  of  these  74  cases  varied  from  no  paralysis  to  death,  the 
percentages  of  above  substances  found  in  each  fluid  gave  no  indication  of 
the  final  outcome. 


(25)  Bloor,  Journ.  Biol.  Chem.,  XXI,  227,  1916. 


219 
CEItEBROSPINAL  MENINGITIS   FlUIDS  TeSTED. 

Successive  fluids   from  twenty-three  cases  of  epidemic  cerebro-spinal 
meningitis  were  tested  with  the  following  result: 

When  patient  was  improving — 

Nitrogen  decreased. 
Non-protein  nitrogen  decreased. 
Creatinine  decreased. 
Urea  increased. 
Sugar  increased. 

When  patient  was  dying — 
Opposite  results  were  obtained. 


Tuberculous  Meningitis  Fluids  Tested. 
Twelve  cases  of  tuberculous  meningitis  were  tested : 


Total   nitrogen 

Non-protein    nitrogen 

Urea  nitrogen 

Creatinine 

Creatine 

Sugar 


varied  from  20.86 
varied  from  13.88 
varied  from     6.66    to 
varied  from       .487  to 
varied  from       .563  to 
varied  from  Traces  to 


to  34.50     in  mgms.  per  100  c.c. 

to  17.25     in  mgms.  per  100  c.c. 

14.18    in  mgms.  per  100  c.c. 

.765  in  mgms.  per  100  c.c. 

.735  in  mgms.  per  100  c.c. 

.060  in  mgms.  per  100  c.c. 


Miscellaneous  Fluids  Tested. 
Nine  miscellaneous  fluids  were  tested  with  the  following  results 


Total 
No.  Case.  Nitrogen. 

2821a  Meningism  typhoid 

3095a  Meningism  endocarditis 

3113a  Meningism  intestinai  trouble 

3244a  Possible  brain  tumor 

3138a  Rheumatism 45  .  25 

?  Syphilis 23.35 

3251  Cerebro  spinal  lues.     Normal  (?)     

3240  Normal  (?) 14.35 

3495  Normal 15 .  70 


Non-protein 
Nitrogen. 


Urea 
Nitrogen.  Creatinine.   Creatine. 


Sugar. 


31.06 
19.38 


365 
350 


.066 
.0806 
.0824 
.051 


TOTAL  NITROGEN  (N  MILLIGRAMS 


O 


Z 
u 
CD 

O  25 

h 

Z 


h 
O 
Q: 

a 


50 


Z 
O 
Z 

O 
h 

z 
u 
o 
cr 
u 

Q. 


75 


100 


~ 

^^ 

■Hi 

■KM 

^" 

^" 

^ 

■~y 

"~ 

- 

H 

A 

R 

T 

• 

N 

O 

,^ 

7 

r 

rO 

s«? 

s 

-F 

^o 

\o 

ni. 

P 

it 

8 

- 

-/ 

- 

\ 

', 

_ 

/ 

.    1 

J 

f 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

, 

i 

/ 

^ 

\ 

i 

f 

^ 

^ 

/ 

o 


TOTAL  NITROGEN  IN  MILLIGRAMS 


25 

Z 
U 

O 

Q: 
h 

z 

I 

< 

u 

L. 
O 

h 
Z 
U 

o 

Q: 
U 
Q. 


75 


100 


n 

r 

— 

C 

H, 

Af 

?1 

■  f 

Nl( 

^-^ 

' 

A 

f 

-N 

^a 

•ir, 

Pc 

lio 

nu 

Hi- 

is 

/ 

< 

\ 

\ 

\ 

\ 

\ 

J  II 

J 

/ 

i 

/ 

/ 

, 

/ 

/ 

/ 

\ 

/ 

1 

\ 

/ 

) 

/ 

\i 

V 

227 

Summary. 


Total        Non-protein        Urea 

Nitrogen       Nitrogen       Nitrogen  Creatinine  Creatine 

in  mgms.       in  mgms.      mgms.  per  mgms.  per  mgms.  per 

per  100  c.c.  per  100  c.c.       100  c.r.  100  c.c.  100  c.c. 


Sugar. 


Poliomyelitis 20. 0 

37  cases 
Epidemic  cerebro-spinal  meningitis       50.  75 

18  cases 

Tuberculous  meningitis 28. 10 

8  cases 
Miscellaneous 19.52 

4  cases 


15.71 

11.93 

.400 

.405 

.0611 

16  cases 

16  cases 

22  cases 

11  cases 

36  cases 

26.62 

11.60 

.476 

Traces 

7  cases 

9  cases 

5  cases 

5  cases 

15.44 

7.93 

.014 

3  cases 

5  cases 

' ".369" 

4  cases 



4  cases 
.0585 
6  cases 

228 


2  a 

o 


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u 


u 


c    . 


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<u 


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o^  o  a!  o 

OJ    O    OJ    !*    O) 

Pi;  cQ  pi;  t>o  ci; 


+ 


3  "w 


^    N    «J    ^    «^ 
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I   »^    a;   iw 


<u  <u 

aa 

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o  o 

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>  >   . 

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cj:  i 

^    ^J 

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u  ~ 

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li 

«  'T- 

Jl'o 

E.- 

C      • 

-  ~ 

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«  - 

i;~ 

.     O-^  _j^  >  -   •   •   • 

b  :z  cr  1^  i-'  =^  5  - :::  Q  Q 


+++ 
++++++++++++ 
++++4-+++++++ 

+  _   + 

+++•7 +++-7H+  + 


+++++++^++++11 


O  M  r^  r-~  CO 

O  O  ^  r';  T^ 


o  o  c  o  o  2  _o  _o_g_o  _o_o_o 
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TT  rj<  ■*  t^  (M  C  ■^  ^1  C  C  I^  ?^1  C^ 


232 


Successive  Punctures  in  Cases  of  Poliomyelitis. 


Total       Non  Prot.        Urea         Creatin-        Creat- 
N.  N.  N.  ine.  ine. 


Sugar. 


3274 

1st  Punct 

2d  Punct 

3d  Punct 21.42 

3196. 

1st  Punct 

2d  Punct 

4th  Punct 19.50 

3310. 

2d  Punct 22.72 

3d  Punct 

3300. 

1st  Punct 21.00 

2d  Punct 20.61 

3322. 

2d  Punct 

3d  Punct :        

3324. 

2d  Punct 

3d  Punct 20.68 

3341. 

2d  Punct 30.00 

3d  Punct 


.396 


.0641 
.0810 


.388 
.429 


.319 


15.54 


13.12 


.0753 
.0824 


14.56 


9.61 


11.0 


7.81 


17.85 


12.50 


16.34 


18.51 


15. i 


Chart  II. 


No. 


Case. 


Non- 
Total      Prot.       Urea   Crea-  Crea- 
N.  N.  N.     tinine.   tine.   Sugar.    Albumin. 


Out- 
Globulin.      Sugar,     come. 


3017a 
3225a 
3222c 
3268a 
3302b 
3363a 
3386a 
3441b 
3441e 
3473a 
3473b 
3487a 
3473d 
3473e 
3487b 
305  7e 
305  7f 
305  7d 
3442a 
3442c 
3472a 
3500a 


E.  C.S.  M., 
E.  C.S.  M., 
E.  C.  S.  M.. 
E.  C.  S.  M.. 
E.  C.  S.  M  .  . 
E.  C.S.  M., 
E.  C.S.  M., 
E.  C.  S.  M., 
E.  C.  S.  M., 
E.  C.  S.  M., 
E.  C.  S.  M., 
E.  C.  S.  M., 
E.  C.  S.  M., 
E.  C.S.  M., 
E.  C.S.  M., 
E.  C.  S.  M . , 
E.  C.  S.  M., 
E.  C.S.  M., 
Influenza. . . 
Influenza. .  , 
Influenza. . 
Strep.  Men. 


45.15 

34.25 
62.20 
24.46 
39.80 

120.00 
36.75 
50.00 
53.75 
95.00 
47.15 
43.45 

250.00 


73.50 
40.25 
138.75 
51.50 
86.30 


26 


86 


14 
16.25 


83  36.48 
52  9.20 
93  11.60 
25  53.28 


60 


..   6.28 

'.'.   ii!i6 


595 
326 


476 
476 
535 


704 


Traces 

+  +  +  + 

+  +  +  + 

+  + 

Recov'd 

Traces 

+  +  + 

+  +  +     no  reduct 

.  Recov'd 

+  +  + 

+  +  + 

+  +  + 

Recov'd 

+  + 

+  + 

+1 

Recov'd 

+  +  +  + 

+  +  +  + 

+ 

Died. 

+  +  +  + 

+  +  +  + 

+  + 

Recov'd 

+  +  + 

+  +  +  + 

± 

Died. 

+  +  +  + 

+  +  +  + 

+ 

Improv, 

+  +  + 

+  +  + 

+  + 

Improv. 
Recov'd 

+ 

Recov'd 

+  +  +  + 

+  +  +  + 

— 

Died. 

+  +  +  + 

+  +  +  + 

+ 

Recov'd 

+  +  +  + 

+  +  +  + 

+  +  +  Recov'd 

+  +  +  + 

+  +  +  + 

— 

Died. 

Traces 

+  +  +  + 

+  +  +  + 

d= 

Died. 

.0628 

+  +  +  + 

+  +  +  + 

± 

Died. 

Traces 

+  +  +  + 

+  +  +  + 

± 

Died. 

+  +  +  + 

+  +  +  + 

— 

Died. 

+  +  +  + 

+  +  +  + 

— 

Died. 

+  +  +  + 

+  +  +  + 

± 

Died. 

+  +  +  + 

+  +  +  + 

— 

Died. 

233 


Successive  Punctures  in  Cases  of  Epidemic  Cerebrospinal  Meningitis. 


Total 
N. 

Non  Prot. 

N. 

Urea 
N. 

Creatin- 
ine. 

Creat- 
ine. 

Sugar. 

3441. 

2d  Punct 

5th  Punct 

120.00 

36.75 

33.47 

21.62 

.... 

3473. 

1st  Punct 50.00 

2nd  Punct 53.75 

4th  Punct 47.15 

5th  Punct 43.45 

3487. 

1st  Punct 95.00 

2d  Punct 250.00 

3044. 

4th  Punct 73.50 

5th  Punct 

6th  Punct 

4332. 

1st  Punct 40.25 

3d  Punct 138.75 


26.62 
21.93 

9.20 
11.60 

45.83 
136.25 

36.48 
53.28 

26.60 


.535 
.476 
.476 


.704 


Traces 

Traces 

.0628 


6.28 


Chart  III. 


No. 


Case. 


Non- 
Total    Prot,    Urea     Crea-   Crea- 
N.         Is.         N.      tinine.   tine.       Sugar. 


Albumin.     Globulin. 


Out- 
Sugar,  come. 


2508b 
2401a 
3115a 
2966a 
3284:a 
3333a 
3284b 
3335a 
3434a 
3284c 
3469a 
3478b 


T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 
T.  B.  Men. 


34.50 
34.40 
29.70 
42.50 
24.35 
26.50 
25.25 
20.86 


6.66 


13.88 
15.44 


7.93 
14.18 
11.50 

7.06 


487 
765 


563      .060 

735      .028 
Traces 
Traces 


+  + 

+  +  + 

+  +  + 

Died 

-f+-h 

+  -h-l- 

+ 

+  -f- 

-f + 

+sl. 

Died 

-f--r 

+  +1 

+  +1 

Died 

+  + 

+  ,    +  + 

± 

Died 

+  +  +  + 

-|--|--f-f 

+ 

+  +  +  + 

+  +  +  + 

+  +  + 

Died 

-H  +  -1--t- 

+  +  +  + 

± 

-I-  + 

+  + 

-i- 

Died 

-I--I--I- 

+  +  + 

+  + 

Died 

+  +  +  + 

+  +  +  + 

-r  + 

Died 

T^  +  + 

+  +  +  + 

-r  + 

Died 

Case  of  Tuberculous  Meningitis. 


Total  N.     Xon.  Prot.  N.    Urea  N.      Creatinine.     Creatine.  Sugar. 


3284. 

1st  Punct 34.50  ....  6.66 

2d  Punct -....  29.70  17.25  7.93 

3d  Punct 26.50  13.88  7.06 


234 


> 


< 

K 
U 


u 


u 


^ 


cu 


u 


No  paral. 
Died. 
Recovered 
completely 

Improved. 
Recovered 
completely 

+++     ++ 
+++     ++ 
+++     ++ 

++     + 
++     + 

+  +     + 

+ 

+  ^^^-   ++ 

-:     + 

+ 
-i    + 
+  ^+   ++ 

++   ^ 

vO'* 

\0  O  CN 

y—i 

•  00       • 

MS  00  00 

lO      . 

ooo 

o     • 

•o    • 

O 

.2  •- 


^"2  "5 

O   O  -tJ 

r-    O  "5 

s  s  s 

t/1    en  cfi 


^^§ 


1-1  lO  PO 

CN  Ov  '-I 
00  O  •^ 
CV)  ro  CO 


.S 

J-   en 

0)   eg  tn   Q  „H 

in    4;   Q,  v^    u, 

DnPic^uiz; 


Tti  00       ■^  o 
-^  m  '^  lo  •* 


s 

o 


235 


Chart   V. 

Relation  of  Cell  Increase  to  Outcome. 
(Condition  After  Approximately  Eight  Weeks.) 


Cytology . 

Complete 
Recovery. 

Weakness  or 

Recovering 

Paralysis. 

Paralyzed. 

Dead. 

Lumbar  Puncture 
in  1st  week  of 
illness 

354 

No  increase 

Slight 

Moderate 

Great 

9 

57 
50 
35 

0 
20 
10 
11 

4 
34 
25 
23 

3 
26 
29 
18 

Second  week .... 

103 

No  increase 

Slight 

Moderate 

Great 

0 

18 
15 

7 

1 
9 

2 

4 

2 

15 
4 

5 

2 

5 

11 

3 

After  2d  week .  . . 

43 

No  increase 

Slight 

Moderate 

Great 

1 

10 

3 

2 

1 
1 

2 
0 

0 

12 

6 

0 

0 
4 
1 
0 

500 

207 

61 

130 

102 

Chart   VI. 

Relation  of  Condition  at  Time  of  Puncture  to  Outcome. 
(Condition  After  Approximately  Eight  Weeks.) 


Weakness  or 

Condition  at  Time      Complete  Recovering 

of  Puncture.            Recovery.  Paralysis.      Paralysis.    Dead. 

No  signs  of  Paralysis.          25  2                      13 
Weakness    or  o  t  h  e  r 

marked  symptoms .  .        108  25                  "30               34 

Paralyzed  in  some  part         18  14                   55               39 


Lumbar  Puncture 
in  1st  week  of 
illness 354 


Second  week.  .  . 

.    103 

No  signs 

Weakness 

Paralyzed  

6 

28 
6 

1 

8 

7 

1 

7 

18 

0 

5 

16 

After  2d  week. . . 

.     43 

No  signs 

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2 

11 

3 

0 
1 
3 

0 

1 

17 

0 
3 

2 

500 

207 

61 

130 

102 

236 


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238 

Chart   X. 

Relation  of  Cytology  to  Chemical  Findings. 


Cytology. 

Albumin 

and  Globulin. 

=t: 

+  _ 

+1 

+  + 

+  +1 

+  +  + 

+  +  +  + 

No  increase ....       23 

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1 

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8 

General  Accuracy  in  Diagnosis. 

Although,  at  the  outset  of  the  epidemic,  the  medical  staff  of  the 
Health  Department  was,  for  the  most  part  inexperienced  in  the  diagnosis 
of  poliomyelitis,  the  percentage  of  errors  made  by  the  diagnosticians  was 
extremely  small,  considering  the  difficulties  they  had  to  contend  with. 

The  following  study  of  4,474  cases,  received  and  treated  in  the  Depart- 
ment Hospitals,  shows  the  result  of  the  diagnosis  arrived  at.  Of  the  4,474 
cases,  96  cases,  after  being  observed  for  some  time  in  the  hospital,  were 
discharged  as  "  nb  illness."  In  49  additional  cases,  the  patient's  disease 
proved  to  be  other  than  poliomyelitis.  Disregarding  the  96  cases  sent  in  for 
observation  as  a  matter  of  precaution,  it  appears  that  actual  errors  in 
diagnosis  occurred  only  in  1.5  per  cent,  of  these  cases.  None  of  the  96 
patients  held  for  observation  developed  any  sickness  within  a  reasonable 
time  after  leaving  the  hospital,  and  in  no  case  did  poliomyelitis  in  the  patient 
or  any  member  of  the  home  household   follow. 

The  final  diagnosis  in  the  49  cases  above  mentioned,  which  were  found 
not  to  be  poliomyelitis,  were  as  follows : 

In  6  cases  there  were  convulsive  manifestations:  Hysteria  (2), 
uremia  and  nephritis  (1),  tetany  (1),  epilepsy  and  arthritis  (1), 
chorea  (1). 

In  15  cases  there  zvas  meningeal  involvement:  Tuberculous 
meningitis  (8),  streptococcus  meningitis  (1),  cerebro-spinal  menin- 
gitis (3),  pneumococcus  meningitis  (1),  meningism  and  gastro-enter- 
itis  ( 1 ) ,  influenzal  meningitis  ( 1 ) . 

In  13  cases  there  was  paralysis  or  deformity:  Rhachitic  pseudo- 
paralysis (1),  cerebral  thrombosis  (1),  post-diphtheritic  paralysis 
(2),  seven-year-old  poliomyelitis  (1),  Pott's  disease  with  kyphosis 
(1),  congenital  calcaneo-valgus  (1),  Bell's  paralysis  (1),  congenital 
tetanoid  pseudo-paralysis  (1),  hemiplegia  (2),  transverse  myelitis 
(1),  cerebro-arteriosclerosis  and  traumatic  supra-orbital  neuritis  (1). 

In  6  cases  there  were  respiratory  systoms:  Pulmonary  tubercu- 
losis (1),  purulent  pleuritis  (1),  broncho-pneumonia  (2),  broncho- 
pneumonia and  pertussis  (2). 

In  8  cases  there  were  acute  infections  or  other  acute  disorders: 
Purulent  peritonitis  (1),  intusussception  and  gastro-enteritis  (1), 
dentition  (1),  cervical  adenitis  and  cellulitis  (1),  malnutrition  and 
spasmophilia  (1),  pericarditis  (1),  septic  arthritis  (1),  measles  (1). 

In  1  case  there  was  idiocy. 


239 

It  is  apparent  that  the  symptoms  of  many  of  the  conditions  here  enum- 
erated so  closely  resemble  those  of  poliomyelitis  that,  for  this  reason, 
prompt  differential  diagnosis  was  often  impossible.  The  proportion  of  eases- 
manifesting  meningeal  symptoms  is  striking;  the  same  is  true  of  the  number 
of  acute  infections  with  respiratory  symptoms. 

Again,  in  a  special  investigation  made  of  1,500  fatal  cases  reported  by 
private  physicians  as  due  to  the  disease,  a  comparatively  low  diagnostic 
error  is  also  recorded.  Of  the  1,500  total  cases,  a  positive  diagnosis  was 
made  in  1,355  cases ;  145  cases  were  diagnosed  as  "  no  illness "  or 
"  undetermined."  In  35  of  the  145  cases  no  diagnostic  report  was  obtainable, 
and  therefore  they  are  not  included.  Of  the  110  cases  remaining,  46  were 
reported  as  "'  no  illness,"  leaving  64  cases  "  undetermined."  Altogether, 
incorrect  diagnoses  were  made  in  52  cases  out  of  the  1,355,  making  an  error 
of  4  per  cent.  The  conditions  other  than  poliomyelitis  for  which  they  were 
incorrectly  diagnosed  were :  Pneumonia,  pulmonary  edema,  gastro-enteritis 
and  cerebral  hemorrhage.  As  direct  cause  of  death,  in  those  cases,  was 
given :  Respiratory  failure  in  828  cases,  or  61  per  cent. ;  cardiac  failure  in 
452  cases,  or  23  per  cent. ;  and  both  respiratory  and  cardiac  failure  in  23 
cases,  or  2  per  cent.  The  diseases  mistakenly  diagnosed  as  poliomyelitis 
were :  Cerebro-spinal  meningitis,  tuberculous  meningitis,  pneumonia, . 
gastro-enteritis,  post-diphtheritis  paralysis,  dysentery  and  pertussis. 

The  results  iiere  mentioned  are  further  corroborated  by  a  more  recent 
study  of  the  total  number  (9,050)  of  cases  occurring  in  the  city  during  the 
twelve  months  of  1916.  Of  the  9,050  cases,  240  were  discharged  by  the 
diagnostician  as  being  incorrectly  diagnosed  poliomyelitis,  making  an  error 
of  2.65  per  cent. 

Diagnostic  Procedure. 

In  this  connection,  it  may  be  interesting  to  describe  briefly  the  outline 
of  the  procedure  in  diagnosis  which  was  carried  out  by  the  diagnosticians 
during  the  1916  epidemic. 

Early  in  July,  the  Chief  Diagnostician  received  instructions  to  visit 
hospitals  throughout  the  city,  on  request,  and  to  discharge  as  not  contagious 
those  patients  whose  history  and  clinical  condition  at  the  time  of  admission, 
and  subsequetly,  did  not  justify  a  diagnosis  of  poliomyelitis.  Later,  about 
August  1st,  these  instructions  were  issued  to  Borough  diagnosticians  also. 
Throughout  the  entire  outbreak  the  regular  procedure  was  followed  in  the 
homes,  the  Chief  and  Borough  Diagnosticians  confirming  or  reversing 
diagnoses  in  doubtful  and  disputed  cases. 

It  w^as  evident  at  the  outset  that,  to  do  this  work  satisfactorily,  some 
definite  criterion,  some  irreducible  minimum  of  evidence  must  be  established, 
in  the  absence  of  which  diagnosis  of  poliomyelitis  could  not  be  sustained. 
To  illustrate :  with  the  exanthemata,  for  instance,  it  is  essential  to  have,  in 
some  form,  evidence  showing  the  existence  of  eruption — past  or  present — 
furthermore,  it  must  persist  for  an  appreciable  time,  certainly  not  less  than 


240 

forty-eight  hours.  Cases  "  sine  eruptione  "  arise  from  time  to  time,  requir- 
ing isolation,  but  positive  official  diagnosis  of  exanthematous  diseases, 
without  any  knowledge  of  an  exanthem,  cannot  be  made  with  safety. 

Equally,  in  the  diagnosis  of  poliomyelitis,  while  the  mild,  or  non- 
paralytic or  abortive  case  is  constantly  to  be  kept  in  mind,  there  must  be 
evidence  of  some  abnormal  condition,  past  or  present,  more  definite  than 
the  general  symptoms  of  fever,  gastro-intestinal  disturbance,  or  rigidity  of 
spine.  The  essential  condition  in  this  disease,  from  the  standpoint  of  the 
clinician,  undoubtedly  is  impairment  of  motion.  If,  in  any  given  case,  the 
disease  be  so  mild,  or  abort  so  quickly  and  completely  that  the  musculature 
remains  wholly  unaffected,  then  that  case  must  fail  of  positive  clinical 
recognition.  Moreover,  all  the  evidence  goes  to  show  that  paralysis  or 
weakness  once  present,  invariably  persists  for  at  least  one  week. 

No  patient  was  discharged  until  examined  by  at  least  two  physicians ; 
until  several  days  intervened  between  the  date  of  discharge  and  the  date 
of  the  original  diagnosis,  and  (in  hospital  cases)  until  the  history  previous 
to  admission  was  investigated.  No  patient  showing  positive  lumbar  puncture 
findings  was  discharged  as  not  contagious. 

In  some  of  the  cases  discharged  a  positive  diagnosis  other  than  polio- 
myelitis could  be  made ;  and  in  others  no  diagnosis  was  possible,  the  patient 
showing  nothing  abnormal  or  a  febrile  condition  only. 

Any  recognized  impairment  of  motion,  let  it  be  ever  so  slight,  coming 
on  recently  and  not  otherwise  to  be  accounted  for,  held  a  patient  as  affected 
with  poliomyelitis.  The  presence  or  absence  of  reflexes  and  electric  tests 
were  not  found  to  be  of  much  aid  in  reaching  conclusions. 

By  following  out  the  foregoing  procedure,  a  high  degree  of  diagnostic 
accuracy  was  thus  obtained  during  the  epidemic,  as  shown  by  the  figures 
already  given. 


CHAPTER   X. 
Prognosis. 

In  poliomyelitis,  more  than  in  any  other  disease  perhaps,  a  distinction 
should  be  made  between  prognosis  as  to  life  and  prognosis  as  to  complete 
recovery  of  function.  But  in  predicting  the  outcome  of  such  a  multiform 
affection  as  this,  either  as  to  life  or  function,  we  should  be  very  guarded  in 
our  opinions. 

Before  the  disease  was  well  known  it  was  an  accepted  axiom  that  in- 
fantile paralysis,  or  poliomyelitis,  was  seldom  if  ever  fatal,  and  that  the 
paralysis  which  followed  was  invariably  permanent.  That  this  disease  can, 
and  often  does,  end  fatally  has  been  clearly  shown  by  the  history  of  past 
epidemics ;  and  it  has  been  frequently  demonstrated  by  clinicians  in  various 
parts  of  the  world  that  complete  recovery  from  paralysis  is  not  only  pos- 
sible, but  by  no  means  uncommon. 

The  prognosis  as  to  life  is  based  on  mortality  statistics  and  upon  the 
extent  of  involvement  and  direction  of  advance  of  the  lesions  in  the  brain 
and  spinal  cord.  But  the  mortality  of  poliomyelitis  varies  greatly,  both  in 
different  epidemics  and  in  difterent  centres  of  the  same  epidemic,  and  even 
in  difterent  points  in  a  single  center.  In  some  localities,  epidemics  have 
shown  great  virulence,  while  in  others  they  have  been  ven,-  mild.  On  the 
whole,  it  would  appear  that  the  mortality  of  European  outbreaks  (see  table 
No.  1  in  the  appendix)  has  been  fairly  high,  higher  than  that  reported  in 
the  majority  of  .-American  outbreaks.  But  the  mortality  at  difterent  times 
and  places  has  fluctuated  considerably,  and  also  in  the  same  place.  Thus 
in  the  Xew  York  epidemic  of  1907,  the  case  fatality  is  estimated  to  have 
been  5  per  cent. ;  in  the  1916  epidemic  in  New  York,  it  was  26.9  per  cent. 

^Moreover,  it  should  be  borne  in  mind  that  the  death  rate  in  an  epidemic 
depends  upon  the  number  of  cases  reported,  and  in  an  epidemic  of  polio- 
myelitis on  whether  the  non-paralytic  or  abortive  cases  are  estimated  or  not. 
Even  when  these  latter  cases  are  estimated,  the  mortality  changes  according 
to  the  thoroughness  with  which  the  estimation  is  made.  Since  a  great  many 
cases  of  this  disease  are  of  the  non-paralytic  or  abortive  type,  which  are 
often  unrecognized  and  unrecognizable  and  therefore  not  estimated,  whereas 
the  severe  and  fatal  cases  are  usually  reported  fully,  the  death  rates  in  polio- 
myelitis should  be  considered  as  approximate  only.  Eor  this  reason,  also, 
the  prognosis  as  to  life,  as  expressed  in  mortality  tables,  is  probably  more 
favorable  than  the  recorded  figures  would  seem  to  indicate. 

Although  children,  as  a  rule,  are  more  commonly  affected  than  adults, 
in  many  epidemics,  the  mortality  has  been  reported  as  being  highest  in 
adults.  In  most  of  the  recorded  epidemics  the  case  fatality  has  been  greater 
from  the  age  of  ten  years  upward.  In  the  epidemics,  on  the  other  hand,  in 
New  York,  in  1907  and  1916,  the  death  rate  was  higher  among  children  in 


242 

the  first  five  years  of  life,  and  after  the  fifth  year  the  mortality  steadily 
declined.     Among  older  children  and  adults  it  was  very  low. 

When  death  occurs  in  an  acute  attack,  it  is  due,  as  a  rule,  to  involve- 
ment of  the  muscles  of  respiration,  and  although  there  is  no  uniformity 
as  to  the  danger  of  the  diseases  upon  any  particular  day  of  the  disease,  life 
is  in  greatest  peril,  apparently,  between  the  third  and  seventh  days — 
the  fourth  and  fifth  days  being  perhaps  the  most  fatal.  After  the  seventh 
day  the  prognosis  as  to  life  is  generally  more  favorable.  Any  involve- 
ment of  the  muscles  of  respiration  or  deglutition  increases  the  seriousness 
of  the  prognosis  and  recovery  is  uncommon  in  the  bulbar  and  ascending 
types  of  the  disease  and  in  the  encephalic  types. 

Regarding  prognosis  as  to  function,  we  must  be  still  more  cautious  in 
our  predictions,  especially  in  the  early  stages  of  the  disease;  and  even  in 
the  later  stages,  it  is  unwise  to  make  any  dogmatic  assertions  as  to  ultimate 
complete  recovery  of  function.  In  general,  a  severe  onset  is  more  unfavor- 
able than  a  mild  onset,  but  this  is  not  true  of  all  cases ;  for  at  times  a 
severe  onset  may  be  followed  by  complete  recovery  of  function  or  mild 
paralysis,  and  a  very  mild  onset  by  severe  or  extensive  paralysis.  Suffice  it 
to  say,  prognosis  as  to  function  is  usually  more  favorable  in  cases  of  mild 
onset,  and  in  all  cases  complete  recovery  from  paralysis  occurs  much  oftener 
than  was  formerly  supposed  and  depends  to  a  great  degree  upon  the  intelli- 
gence and  persistence  of  expert  orthopaedic  and  neurologic  after-care. 

After  the  onset,  in  most  cases,  a  period  of  spontaneous  improvement 
takes  place,  beginning  with,  or  slightly  before,  the  disappearance  of  the 
tenderness,  and  progressing  toward  complete  functional  recovery.  This 
spontaneous  improvement  may  last  some  six  months  to  a  year  or  more. 
Most  of  the  complete  recoveries  occur  in  the  first  half  year,  but  some  occur 
during  the  second  half,  and  a  few  cases  are  reported  to  have  recovered  from 
paralysis,  by  prolonged  treatment  after  several  years. 

Sufficient  data  are  not  available  from  the  recent  epidemic  in  New 
York  to  give  full  comparative  figures  as  to  the  proportion  of  complete 
functional  recoveries  to  permanent  paralysis  which  may  occur.  But  the 
results  obtained  in  the  Health  Department  hospitals,  in  the  care  of  polio- 
myelitis patients,  may  serve  as  a  type  of  the  prognosis  of  the  disease  as  it 
was  observed  in  the  city  when  the  cases  were  properly  treated. 

Of  3,441  cases  treated,  in  the  four  Department  hospitals,  716  died, 
giving  a  mortality  of  16  per  cent.  Of  the  cases  discharged  after  tieatment, 
as  wholly  or  partially  recovered,  1,223  cases  were  discharged  with  "no, 
visible  paralysis,"  and  2,526  cases  were  discharged  with  "  visible  paralysis." 
In  other  words,  32.6  per  cent,  of  the  cases  treated  showed  complete  func- 
tional recovery,  or  had  not  shown  paralysis  at  any  time  in  the  course  of  the 
disease,  while  67.4  per  cent,  showed  remaining  paralysis  in  some  degree. 
Of  2,715  cases  followed  up  carefully  in  the  homes  it  was  found  that  1,885 
had  a  serious  paralysis  of  one  or  both  lower  limbs,  and  were  unable  to  walk; 


243 

530  more  were  partially  paralyzed  in  the  lower  limbs,  although  still  able 
to  walk;  273  had  one  or  both  arms  totally  paralyzed. 

It  should  be  noted,  however,  that  the  average  number  of  days  per 
patient  during  which  these  cases  were  under  treatment  at  the  hospitals  was 
32.4,  or  scarcely  more  than  a  month;  none  was  under  treatment  for  two 
months.  It  is  now  known  that  marked  or  great  improvement  may  be  induced 
in  paralyzed  cases  by  correct  treatment,  at  a  much  later  period  than  was 
formerly  credited.  We  have  every  reason  to  believe,  therefore,  that  the 
cases  which  still  remained  paralyzed  after  such  a  short  treatment  in  the 
hospitals  would,  with  a  prolonged  treatment  for  a  period  of  six  months  or 
more,  show  a  larger  proportion  of  complete  recoveries  of  function  than 
here  given,  and  that  the  deformities,  at  least,  in  these  cases  would  be  greatly 
lessened. 

This  belief  is  all  the  more  reasonable  because  the  large  majority  of 
the  patients  treated  were  under  ten  years  of  age — as  indeed  were  most  of 
the  cases  occurring  in  the  city — and  according  to  all  authorities  on  the 
disease  (Wickman,  Leegaard,  Lovett,  et  al.),  age  is  an  important  factor 
in  prognosis ;  the  prognosis  as  to  recover}-  of  function  is  considerably 
more  favorable  in  young  children  than  in  older  children  and  adults. 

What  has  been  stated  concerning  the  prognosis  of  the  cases  treated  in 
the  Department  hospitals  may  be  considered  as  approximately  true  for  all 
cases  occurring  in  the  city  in  which  there  was  suitable  treatment.  The 
results  of  the  1916  epidemic  have  taught  us  many  lessons,  but  one  of  the 
most  valuable  of  these  relates  to  the  prognosis  of  poliomyelitis,  namely, 
that  though  this  is  undoubtedly  a  serious  epidemic  affection,  the  prognosis 
of  the  disease,  both  as  to  life  and  as  to  function,  is  by  no  means  so  unfavor- 
able as  is  the  case  in  several  other  acute  infectious  diseases  with  which  we 
have  been  more  familiar,  but  which,  on  this  account,  we  have  held  in  less 
fear  and  respect. 


CHAPTER   XL 

Record  of  Treatment  Employed, 

Treatment  in  Health  Department  Hospitals. 

Inasmuch  as  more  than  one-half  of  those  living  twenty-four  hours  after 
the  onset  of  poliomyelitis  were  treated  in  the  hospitals  of  the  Health  Depart- 
ment, unusual  opportunities  have  been  afforded  for  the  clinical  observation 
and  study  of  the  disease. 

In  the  treatment  of  these  cases  particular  attention  was  paid  to  serum 
therapy,  especially  with  human  serum,  in  the  hope  that  it  would  give  favor- 
able results;  to  intraspinal  injection  of  adrenalin  based  upon  physiological 
deductions  and  endorsed  by  one  of  the  best  known  physiologists  in  the 
country ;  to  mechanical  means  of  maintaining  respiration  in  cases  of  respira- 
tory paralysis;  to  the  internal  administration  of  antiseptics  (urotropin)  ;  and 
to  orthopedic  treatment,  in  paralyzed  cases,  by  mechanical  supports,  plaster 
dressings,  braces,  etc. 

The  treatment  of  cases  may,  for  purposes  of  description  be  divided  into 
(1st)  symptomatic;  (2nd)  supporting;  (3rd)  antiseptic;  (4th)  physiologi- 
cal; (5th)  serum  therapy;  (6th)  hydro  therapy;  (8th)  orthopedic. 

1.  Symptomatic  Treatment — 

This  was  largely  devoted  to  the  alleviation  of  pain,  a  constant  and 
depressing  symptom  in  the  first  week  after  admission.  For  this,  anodynes 
and  hot  water  baths  were  found  to  be  most  efficacious  in  giving  relief.  An- 
other cause  for  symptomatic  treatment  was  dyspnoea,  for  which  mechanical 
appliances  were  used.  Many  forms  of  apparatus  were  tried,  but  the  only 
measure  that  seemed  to  yield  definite  results  was  the  carefully  supervised 
inhaling  of  oxygen  under  pressure,  with  the  ordinary  inhaling  cone.  This 
method  relieved  the  dyspnoea  and  allowed  the  pulse  to  regain  its  strength 
in  a  shorter  time  than  did  any  other  method  employed. 

2.  Supporting  Treatm>ent — 

This  included,  principally,  the  administration  of  food  in  proper  amounts. 
A  large  number  of  the  patients  admitted  to  the  hospitals  suffered  from 
paralysis  of  the  muscles  of  deglutition ;  and  only  by  the  most  careful  super- 
vision of  the  administration  of  the  proper  quantities  of  food  were  the 
patients  kept  alive.  These  cases  demanded  constant  medical  attention  and 
nursing.  In  cases  of  long  standing,  tonics  were  given  when  indicated,  but 
such  cases  were  comparatively  few  in  number. 

3.  Antiseptic  treatment — 

This  consisted  of  the  administration  of  urotropin  more  particularly.  At 
one  of  the  hospitals  of  the  Department,  namely,  the  Willard  Parker  Hospital, 


245 

urotropin  was  used  throughout  the  epidemic ;  at  another,  the  Riverside  Hos- 
pital, it  was  but  Httle  used.  As  far  as  any  definite  effects  were  observable, 
the  cases  seemed  to  do  equally  well  with  and  without  its  use. 

Under  antiseptic  treatment  may  also  be  included  those  prophylactic 
measures  which  were  employed  for  the  protection  of  nurses,  doctors  and 
others,  in  attendance  upon  patients.  At  the  beginning  of  the  epidemic  it 
was  recommended  that  all  those  in  immediate  contact  with  patients  should 
wear  gauze  masks,  in  addition  to  the  ordinary  prophylactic  procedures 
usually  carried  out  in  hospitals  for  infectious  diseases,  and  an  attempt  was 
made  to  follow  the  recommendations.  The  great  amount  of  work  that  was 
to  be  done,  with  the  small  number  of  employees  available  to  do  it,  very  soon 
showed  the  impracticability  of  this  measure ;  and  at  the  end  of  a  month  the 
order  for  its  enforcement  was  rescinded.  No  attending  physician,  nurse 
or  other  employee  in  the  hospitals  developed  the  disease  during  the  epidemic. 

4.  Physiological  treatment — 

This  treatment  consisted  in  the  intraspinal  administration  of  adrenalin, 
on  the  hypothesis  that  the  congested  membranes  of  the  cord  could  be  restored 
to  their  normal  physiological  condition  by  the  introduction  of  this  substance 
into  the  spinal  canal  after  lumbar  puncture.  The  results  obtained  did  not 
justify  its  use;  it  was  not  found  to  be  superior  to  other  forms  of  treatment. 

Simple  lumbar  puncture,  on  the  other  hand,  often  relieved  the  pressure, 
either  when  accompanied  by  symptoms  or  not ;  this  measure  was  frequently 
followed  by  rapid  and  permanent  improvement. 

5.  Serum  therapy — 

Serum  therapy  of  various  kinds  was  tried.  In  some  cases  treated 
outside  of  the  hospitals,  and  the  effects  of  which  were  observed  after  ad- 
mission, diphtheria  antitoxin  was  administered — a  most  unwarrantable  pro- 
cedure.    No  good  results  were  visible. 

Normal  horse  serum,  intraspinally,  given  on  the  theory  that  some  of  the 
antibodies  contained  in  the  serum  would  produce  beneficial  effects,  was 
tried  in  a  series  of  cases  and  many  favorable  reports  were  made.  A  com- 
plete analysis  of  these  cases  revealed  the  fact  that  its  use  was  not  justified; 
nor  is  there  any  scientific  reason  to  believe  in  a  possible  specificity  of  such 
serum  in  the  treatment  of  poliomyelitis. 

Normal  human  serum  from  properly  tested  donors,  i.  e.,  healthy  persons 
who  never  had  poliomyelitis,  was  tried  in  a  series  of  cases  with  many  ap- 
parently striking  examples  of  recovery ;  but  these  were  paralleled  by  other 
striking  recoveries  in  patients  who  received  no  serum. 

Immune  human  serum  from  persons  who  had  recently  recovered  from 
an  attack  of  poliomyelitis  was  employed  in  a  large  number  of  cases  with 
some  beneficial  results ;  but  none  of  these  gave  sufficient  evidence  of  curative 
effect  to  justify  the  adoption  of  such  serum  as  a  specific  cure  for  the 
disease. 


246 

6.  Hydro-therapy — 

Hydrotherapeutic  measures  were  restricted  to  the  use  of  the  simple  baths 
and  enemas  commonly  employed  in  children's  diseases.  Aside  from  the 
relief  of  pain,  frequently  experienced  by  patients  from  the  effect  of  warm 
baths,  no  particularly  favorable  results  were  noted. 

Electro-therapy,  which  has  been  recommended  by  some  authorities  for 
the  treatment  of  poliomyelitis,  was  not  used  in  the  hospitals  of  the  Depart- 
ment. 

7.  Orthopedic  treatment — 

The  most  important  service  in  the  treatment  of  cases  in  the  hospitals 
was  that  rendered  by  the  orthopedic  surgeons  in  the  treatment  of  paralysis 
and  correction  of  deformities.  The  long  period  of  quarantine  (six  to  eight 
weeks)  in  the  hospitals  carried  the  patients  over  the  stage  of  pain  and  up 
to  the  point,  in  many  instances,  of  beginning  contractures.  By  close  obser- 
vation the  orthopedic  surgeons  were  able  to  determine  just  when  to  apply 
plaster  dressings,  and  when  to  remove  them  to  fit  braces  on  the  patients. 
Opportunity  offered  also  for  beginning  massage  of  the  affected  muscles  by 
the  masseuses,  under  the  immediate  direction  of  the  surgeons,  who  could 
point  out  to  them  exactly  what  muscles  were  to  be  massaged  and  which 
were  not.  In  addition,  it  allowed  the  patients  to  become  acquainted  with 
the  masseuses,  so  that  when  the  after-care  was  continued  in  the  homes 
there  was  no  fear  to  be  allayed  on  account  of  the  unaccustomed  treatment. 

Following  is  a  summary  of  the  treatments  given  at  the  Department 
Hospitals : 


Treatments. 


Willard    Kingston  Queens- 

Parker       Avenue     Riverside      boro 
Hospital.   Hospital.   Hospital.  Hospital. 


Total. 


Serum    34 

Adrenalin    2 

Quinine     8 

Horse    Serum    3 

Diphtheria    Antitoxin    1 

Lumbar    Puncture    405 

Lumbar  Puncture  and  Adrenalin... 

Serum  X   (Special  Jobling  Serum).  5 

Auto-inoculation    5 

Immune  and   Normal   Serum 2 

Spinal  Fluid    

Immune  Serum 114 

Normal   Blood    Citrated 2 

Anti-meningitis   Serum 3 

Anti-influenza   Serum    1 

Symptomatic    1,489 

Convalescent    Serum — Spinal    

Convalescent    Serum — Muscular    ... 

Total   2,074 

i         .  =^ 


3 

2 

39 

11 

23 

36 
8 

98 

101 

5 

6 

328 

158 

65 

956 

79 

21 

100 

5 

29 

34 
2 

11 

11 

114 

2 

3 

1 

563 

929 

102 

3,083 

9 

9 

6 

•• 

6 

1,049 


1,203 


190 


4,516 


247 

The  clinical  reports  from  the  four  hospitals  of  the  Department,  repre- 
senting as  they  do  the  observations,  clinical  notes  and  conclusions  of  lead- 
ing clinicians  in  the  four  large  boroughs  of  the  city,  have  much  value  for 
the  practicing  physician. 

Summary  of  Treatments  at  Willard  Parker  Hospital. 

At  Willard  Parker  Hospital  the  following  data  are  summarized  from 
the  bedside  notes  and  histories  where  immune  human  serum  was  given 
intraspinally  during  the  paralytic  stage  of  the  disease  in  142  cases : 

Duration  of  Illness  on 
Age.                                                      Admission. 

Male 75           6  months  and  under.      3              1  day   3 

Female   67           7  to  12  months 14              2  days  27 

1  to     2  years 55              3  days  41 

142          3  to  5     years 45              4  days  16 

6  to  10  years 21              5  days  11 

Over  21  years 4              6  days  8 

7  days  10 

142              8  days  1 

9  days  1 

10  days 1 

1 1  days  1 

12  days  1 

14  days  1 

Not  given 20 

142 
The  history  of  the  number  of  days  ill  previous  to  admission  is  probably 
inexact  in  very  many  cases  as  parents  in  many  instances  dated  beginning  of 
illness  from  onset  of  paralysis. 

Temperature  on  Admission. 

98.6  to  100° 41 

100    to  102° 70 

102    to  103° . , 20 

Over  103° 11 


142 

Paralysis  on  Admission. 

Involvement  of  one  upper  limb  only 9 

Involvement  of  one  lower  limb  only 17 

Involvement  of  one  upper  and  one  lower 3 

Involvement  of  both  upper  limbs 6 

Involvement  of  both  lowers ." 30 

Involvement  of  all  extremities 11 

Involvement  of  facial  only 13 

Involvement  of  facial  and  uppers 11 

Involvement  of  one  upper  and  two  lowers 3 

Involvement  of  facial,  intercostal  and  abdominal  muscle 1 


248 

Involvement  of  one  upper,  one  lower  and  intercostals 1 

Involvement  of  muscles  of  deglutition  only 3 

Involvement  of  facial,  deglutition  and  both  lowers 1 

Involvement  of  all  extremities  and  intercostals 3 

Involvement  of  all  extremities  and  deglutition 2 

Involvement  of  facial  and  deglutition 2 

Involvement  of  both  lowers  and  abdominal  muscles 3 

Involvement  oi  one  lower,  two  uppers  and  intercostals 2 

Involvement  of  one  upper  and  intercostals 

Involvement  of  both  uppers  and  deglutition 

Involvement  of  facial,  deglutition  and  intercostals 

Involvement  of  diaphragm  and  intercostals 

Involvement  of  facial  and  one  lower  extremity 

Involvement  of  intercostals  only  with  stupor 2 

Involvement  of  deglutition  and  intercostals 2 

Involvement  of  facial  deglutition  and  both  uppers 2 

Involvement  of  facial  and  both  lowers 3 

Involvement  of  intercostals,  both  lowers  and  abdominal  muscles.  ...  3 

Involvement  of  deglutition,  intercostals  and  one  upper 1 

Involvement  of  -deglutition  and  one  upper 2 

Involvement  of  facial,  intercostals,  both  uppers  and  one  lower 1 


142 


Serum  Treatment. 
The  serum  was  administered  as  soon  as  possible  after  admission.  A 
few  cases  whose  paralysis  became  progressive  after  admission  naturally 
received  their  serum  at  a  longer  interval  after  admission.  A  few  cases 
which  resembled  intercostal  paralysis  at  onset  and  later  proved  to  be  broncho- 
pneumonia received  serum  several  days  after  admission  to  the  hospital. 

Serum  received  within  12  hours  after  admission 88 

Serum  received  within  12  to  24  hours  after  admission 34 

Serum  received  within  24  to  48  hours  after  admission 12 

Serum  received  within     3  days  after  admission 2 

Serum  received  within     4  days  after  admission 1 

Serum  received  within     6  days  after  admission 1 

Serum  received  within     7  days  after  admission *2 

Serum  received  within     9  days  after  admission f  1 

Serum  received  within  21  days  after  admission 1 

The  types  of  serum  used  were  (a)  poliomyelitis  convalescent  human 
serum  referred  to  as  "  Immune  serum,"  (b)  normal  human  serum,  (c)  nor- 
mal horse  serum.  The  immune  serum  was  taken  from  individuals  who  had 
recovered  from  poliomyelitis  at  intervals  of  a  few  months  to  several  years 

*  One  Tbc.  Meningitis.     One  Broncho-pneu. 
t  Broncho-pneu. 


249 


previously.  The  serum  was  taken  only  from  those  in  good  health.  A 
Wassermann  test  was  made  on  all  specimens  of  human  serum  before  they 
were  accepted  for  use.     Administration  was  intraspinal. 

Patients. 

Normal  human  serum  was  administered  to 34 

Normal  horse  serum  was  administered  to 3 

"  Immune  "  human  serum  was  administered  to 93 

Serum,  type  not  stated,  was  administered  to 12 

4  patients  received     8  c.c.  of  serum. 

13  patients  received  10  c.c.  of  serum. 

121  patients  received  15  c.c.  of  serum. 

4  patients  received  20  c.c.  of  serum. 

In  a  few  cases  within  3  or  4  hours  after  the  introduction  of  the  serum 
there  was  a  sharp  rise  or  fall  in  temperature.  In  the  other  cases  the  tem- 
perature remained  relatively  the  same  for  24-72  hours,  but  then  began  to 
fall.  In  the  progressive  cases  which  resulted  fatally,  the  temperature  usually 
continued  to  climb  until  death  occurred.  As  a  rule,  after  the  serum,  there 
were  more  or  less  well  marked  signs  of  meningeal  irritation  manifested  by 
rise  in  temperature,  irregular  cardiac  action,  retraction  of  head,  stiffness  of 
neck  and  back,  general  hyperesthesia,  increased  irritability  and  in  the  more 
severe  cases  stupor  or  delirium.  The  percentage  of  the  more  marked  reac- 
tion was  relatively  the  same  for  all  types  of  serum. 

Temperature  dropped  1°  in  9  cases.  Temperature  rose  1°  in  25  cases. 

Temperature  dropped  2°  in  7  cases.  Temperature  rose  2°  in  22  cases. 

Temperature  dropped  3°  in  2  cases.  Temperature  rose  3°  in    4  cases. 

Temperature  rose  5°  in    2  cases. 

Temperature  rose  7°  in    1  case. 

The  temperature  remained  relatively  the  same  in  70  cases.  A  severe 
meningeal  reaction  occurred  in  11  cases. 

A  second  dose  of  serum  was  given  after  an  interval  of  24  hours. 

First — When  the  general  condition  of  patient  did  not  seem  better. 

Second — When  the  temperature  still  remained  elevated  or  there  was 
still  evidence  of  progression  of  the  involvement. 

Third — When  there  was  no  well  marked  signs  of  meningeal  irritation 
after  the  first  dose. 

Thirty-six  patients  received  second  injections  of  serum: 

9  patients  received  normal  human  serum. 

3  patients  received  normal  horse  serum. 
24  patients  received  normal  immune  human  serum. 

1  patient    received     8  c.c.  of  serum. 

1  patient    received  10  c.c.  of  serum. 
34  patients  received  15  c.c.  of  serum. 


250 

The  temperature  after  second  dose  reacted  as  follows : 

Drop  of  1° 2  cases. 

Rise  of  1  ° 2  cases. 

Rise  of  2° 2  cases. 

.     Rise  of  3° 2  cases. 

Rise  of  5° 1  case. 

Relatively  no  change  in  24  hours 27  cases. 

Signs  of  severe  meningeal  irritation  occurred  in  four  cases. 

A  third  dose  of  serum  was  administered  after  an  interval  of  24  hours 
to  two  patients.  Each  received  15  c.c.  of  "immune"  serum.  There  were 
no  reactions. 

Serum  Treatment  in  Pre-paralytic  Cases  at  the  Willard  Parker 

Hospital. 
Clinical  notes  on  17  cases  in  whom  immune  serum  was  used  in  the 
pre-paralytic  stage  are  summarized  as  follows : 

•  Age. 

1  to    2  years 3 

3  to    5  years 11 

6  to  10  years '  3 

Days  III  on  Admission. 

1  day 2  Two  cases  receiving  treatment  before  admission : 

2  days 6 

3  days 3  111  2  days 1 

4  days 1  111  5  days 1 

5  days 4 

6  days 1 

Temperature  on  Admission. 

98.6-100 2         Those  receiving  treatment  before  admission: 

100-102 7        98.6  to  102 1 

Over  102 6         Over  102 1 

Condition  on  Admission. 
Following  is  the  physical  condition  as  determined  on  admission : 

Weakness  of  both  lower  extremeties  and  rigidity  of  neck 4 

Weakness  of  one  upper  extremity  only 1 

Tremor  of  an  upper  extremity  with  rigidity  of  neck 1 

Weakness  of  neck  and  back  only 1 

Weakness  of  back  and  both  lowers 2 

Rigidity  of  neck  alone 2 

Uncertain  gait  only 1 

Rigid  neck,  uncertain  gait  and  tremor  of  uppers 1 

Semi-comatose,   slightly  rigid  neck,  flaccidity  of  extremities    (died 

32  hours  after  admission) 1 


251 

Two  cases  having  had  one  or  more  treatment  with  immune  serum 
prior  to  admission,  had^  on  admission : 

Weakness  of  neck  and  back  only 1 

Signs  of  marked  meningeal  irritation 1 

One  case  showed  some  rigidity  of  neck  on  flexion.    Temperature  101 

and  spinal  fluid  of  type  found  in  poliomyelitis 1 

Amount  of  Serum  and  Number  of  Treatments. 

Fifteen  c.c.  of  serum  was  the  usual  dose.  One  patient  received  one 
injection,  of  8  c.c. 

Three  patients  received  one  injection  each  of  normal  serum. 

Two  patients  received  two  injections  each  of  normal  serum. 

Ten  patients  received  one  injection  each  of  immune  serum. 

One  patient  received  two  injections  each  of  immime  serum. 

One  patient  received  two  injections  of  immune  serum  before  admission 
and   (^one  when  admitted.) 

One  patient  received  one  injection  of  immune  serum  before  admission 
and   (one  when  admitted.) 

Results  of  Administration  of  Serum. 

The  usual  immediate  response  following  the  introduction  of  serum  was 
a  varying  degree  of  meningeal  irritation,  stillness  of  neck  and  back  in  mild 
cases,  retraction  of  head,  rigid  neck  and  back,  marked  irritability  and  hyper- 
aesthesia,  Kernigs  reflex  present  and  sometimes  slight  stupor  in  the  more 
severe  cases.  In  this  series  there  were  five  well  marked  reactions  and 
three  very  severe  ones. 

The  temperature  in  five  instances  rose  one  to  four  and  a  half  degrees 
following  introduction  of  serum,  but  the  usual  tendency  was  for  the  tem- 
perature to  fall,  reaching  normal  in  from  24  hours  to  6  days. 

Fourteen  cases  failed  to  develop  any  farther  manifestations  of  the 
pathologic  process,  returning  to  normal  in  a  few  days  or  weeks.  Two  cases 
went  on  to  paralysis  after  the  administration  of  the  normal  serum.  One 
case  admitted — three  days  ill  on  admission — temperature  102  degrees,  with 
weakness  of  muscles  of  back  and  right  lower  extremity,  developed  paralysis 
of  both  loAver  extremities.  There  was  a  severe  reaction  after  the  serum 
was  given.  Finally,  in  another  case,  admitted  with  temperature  101  de- 
grees, which  dropped  to  normal  within  four  hours  when  normal  serum  was 
introduced  there  was  no  reaction  but  the  patient  developed  paralysis  of  one 
upper  extremity. 

One  case  received  normal  human  serum.  Temperature  104  degrees  on 
admission  fell  to  102  degrees,  then  continued  rising  to  107  degrees  at  time 
of  death.  Pulse  rose  from  100  to  160,  respirations  thirty.  Patient  was 
comatose.  No  paralysis,  but  general  flaccidity.  Died  thirty-two  hours  after 
admission. 


252 

Of  these  18  cases,  1  died  and  2  developed  paralysis.  The  condition  of 
5  cases  was  temporarily  much  worse  as  a  result  of  meningeal  reaction,  caused 
by  the  serum.  In  three  cases  the  reaction  was  so  severe  as  to  make  the 
prognosis  very  grave  for  several  days. 


Treatment  With  Quinine. 

In  six  cases,  quinine  and  urea  hydrochloride  was  used  intraspinally 
because  of  its  ready  solubility  and  rapid  absorption.  It  was  administered 
as  follows,  promptly  on  admission  of  the  patient: 

Patients  under  five  years  of  age  received  grains  ten  (X)  intra- 
muscularly, then  grains. three  (III)  per  mouth  three  hours  later  and 
continued  every  three  hours  for  the  next  twenty-four  hours. 

Patients  over  five  years  of  age  received  grains  twenty  (XX) 
intramuscularly,  then  grains  five  (V)  per  mouth  three  hours  later 
and  continued  every  three  hours  for  the  next  twenty-four  hours. 

The  history  of  the  six  cases  thus  treated  is  as  follows : 

Case  1.  Age,  two  years.  Ill  three  days  on  admission,  tempera- 
ture 103°.  Involvement  of  all  four  extremities,  intercostal  and  ab- 
dominal mpscles.  Temperature  rose  to  106°.  Patient  died  fourteen 
hours  after  admission. 

Case  2.  Age,  nine  months.  Ill  two  days  on  admission.  Tem- 
perature, 102.6°.  Involvement  of  all  four  extremities  and  abdominal 
muscles.  Developed  paralysis  of  intercostals.  Temperature  con- 
tinued rising  to  105°.     Died  twenty-eight  hours  after  admission. 

Case  3.  Age,  three  years.  Ill  three  days  on  admission.  Tem- 
perature, 104°.  Involvement  of  left  side  of  face  and  muscles  of 
deglutition.  Developed  paralysis  of  intercostals.  Died  seventeen 
hours  after  admission.  Temperature  fell  to  103°  about  four  hours 
after  admission,  then  rose  to  107°  eight  hours  later,  and  was  104° 
at  time  of  death. 

Case  4.  Age,  seven  years.  Ill  five  days  on  admission.  Tem- 
perature, 102°.  Complete  paralysis  of  both  lower  extremities,  weak- 
ness of  muscles  about  both  shoulders  and  of  back.  Temperature 
arose  to  104°  about  six  hours  after  admission,  then  fell  to  100°  at 
the  end  of  the  first  twenty-four  hours.  The  condition  at  the  end  of 
the  twenty-four  hours  was  weakness  of  muscles  about  right  shoulder, 
paralysis  of  muscles  about  left  shoulder  and  paralysis  of  both  lower 
extremities  and  weakness  of  back  muscles.  Four  weeks  later  muscles 
about  left  shoulder  had  practically  recovered  from  paralysis.  At  the 
time  of  discharge  (end  of  eight  weeks)  the  paralysis  in  the  lower 
extremities  had  not  improved. 

Case  5.  Age,  three  years.  Ill  four  days  on  admission.  Tem- 
perature, 102°.  Weakness  of  muscles  of  left  thigh  and  of  back  and 
neck.  Phonation  slurring,  slightly  stuporous.  Twenty-four  hours 
later  temperature  had  fallen  to  about  normal  and  remained  there. 
There  was  irregularity  in  volume  and  rythm  of  respirations,  paralysis 
of  muscles  of  left  thigh  and  was  still  slightly  stuporous.  Three  days 
later  respirations  and  mental  condition  were  normal.  Paralysis  of 
left  thigh  cleared  up  in  about  four  weeks. 


253 

Case  6.  Age,  two  and  one-half  years.  Ill  one  day  on  admission. 
Temperature,  101°.  Slight  weakness  of  left  facial  muscles  and  stiff- 
ness of  neck.  Gait  ataxic.  Six  hours  later  temperature  rose  to  104°. 
At  the  end  of  twenty-four  hours  temperature  was  100°  and  reached 
normal  on  the  fifth  day.  Twenty-four  hours  after  admission  the 
patient  was  delirious  and  stuporous.  Intercostal  muscles  apparently 
paralyzed.  The  intercostal  involvement  lasted  three  days,  after  which 
time  costal  breathing  began  to  return.  At  time  of  discharge  (end  of 
eight  weeks)  there  was  no  apparent  paralysis  or  weakness. 

It  is  difficult  to  draw  any  conclusions  as  to  the  efficiency  or  non-efficiency 
of  any  form  of  specific  therapy  in  poliomyelitis  as  we  have  seen  parallel 
cases,  one  receiving  a  specific  form  of  treatment  and  the  other  merely 
symptomatic  treatment,  pursue  exactly  similar  courses. 

It  seems  fair  to  assume  that  quinine  (1)  does  not  arrest  severe  pro- 
gressive cases,  (2)  does  not  hasten  the  recovery  from  a  paralysis,  (3)  does 
not  absolutely  prevent  the  onset  of  a  paralysis  when  administered  in  the 
early  stages,  (4)  may  be  of  some  benefit  in  the  so-called  pre-paralytic  phase. 
As  the  cases  received  in  this  hospital  had  usually  reached  the  paralytic  stage 
this  conclusion  could  not  definitely  be  determined. 

Summary  of  Treatments  at  the  Kingston  Avenue  Hospital. 

At  Kingston  Avenue  Hospital,  as  at  the  other  Department  hospitals, 
cases  which  were  recognized  clinically  as  of  a  mild  type  and  with  no  serious 
or  threatening  symptoms,  were  treated  symptomatically  and  no  special 
methods  directed  at  the  cause  of  the  disease  process  were  employed.  Of 
the  1,017  cases  cared  for  at  this  hospital,  through  the  full  period  of  isola- 
tion 488  received  special  treatment  of  some  kind.  In  328  cases  lumbar 
puncture  was  used.  In  209  a  single  puncture  to  relieve  severe  mehingitic  or 
hydrocephalic  symptoms,  and  in  119  multiple  punctures,  and  of  these  121 
died — Zl  per  cent. 

In  27  auto-inoculation  intramuscularly  with  spinal  fluid  was  used. 
Among  these  there  were  15  deaths — (56  per  cent.) 

In  98  horse  serum  was  used  intraspinally  and  intramuscularly  with  35 
deaths  (35  per  cent.).  Of  the  63  cases  which  recovered,  in  22  the  records 
of  paralysis  at  admission  and  discharge  were  not  sufficiently  complete  to 
report ;  in  5  cases  paralysis  which  was  present  on  admission  had  disappeared 
on  date  of  discharge;  in  13  paralysis  had  improved  greatly  between  admis- 
sion and  discharge ;  in  12  paralysis  had  improved  moderately  between  admis- 
sion and  discharge ;  in  10  paralysis  had  improved  slightly  between  admission 
and  discharge ;  in  1  paralysis  had  not  improved  between  admission  and 
discharge. 

In  5  diphtheria  antitoxin  was  used  with  3  deaths. 

In  11  cases  adrenalin  was  used  with  9  deaths. 

In  19  cases  immune  (or  convalescent)  serum  v/as  used  intraspinally 
in  11  and  intramuscularly  in  8  cases  with  8  and  5  deaths  respectively. 

Lumbar  puncture  and  the  various  types  of  treatment  having  that  as 
their  basis  were  used  in  only  the  more  severe  types  of  cases. 


254 

As  paralysis  had  already  supervened  in  practically  all  the  cases,  influence 
of  the  treatment  as  a  preventive  measure  was  not  determined. 

It  seemed,  however,  that  improvement  of  the  paralysis  was  more  rapid 
in  cases  in  which  lumbar  punctures  were  performed.  The  relief  of  hydro- 
cephalic symptoms  following  puncture  was  marked  and  often  complete. 

Best  results-  were  obtained  with  simple  and  multiple  puncture  and  with 
a  combination  of  puncture  and  horse  serum. 

Summary  of  Treatments  at  Riverside  Hospital. 

At  Riverside  Hospital,  in  259  of  the  665  cases,  special  treatment  was 
used. 

Lumbar  puncture  in  156  cases  (61  toxic  and  95  non-toxic)  with  21 
deaths  (13.4  per  cent.).  Of  these  deaths,  13  were  in  the  toxic  group  and 
5  were  in  the  non-toxic  group. 

Of  81  cases  treated  with  adrenalin  intraspinally,  as  advised  by  Dr. 
Meltzer,  35  died,  giving  a  death  rate  of  43  per  cent.  Sixty  were  toxic  and 
21  non-toxic.  Of  these  6  were  non-paralytic,  all  of  extremely  toxic  type  and 
all  but  one  dying  within  48  hours  of  admission,  the  other  75  cases  having 
paralysis  of  all  degrees  of  severity  and  extent. 

Of  60  toxic  cases  27  died — 45  per  cent. 

Of  21  non-toxic  cases  8  died — 38  per  cent. 

Of  24  cases  treated  with  adrenalin  intramuscularly  14  died — 63.6  per 

cent.  Eighteen  were  toxic,  of  whom  13  died — 72.02  per  cent.  Non-toxic,  4, 
of  which  one  died — 25  per  cent.  Two  were  non-paralytic  prostrated  mori- 
bund cases,  living  only  1  and  2  days  respectively,  the  remainder  having 
paralysis  of  varying  degrees. 

Summary  of  Treatments  at  Queensboro  Hospital. 

At  the  Queensboro  Hospital  43  cases  were  treated  by  spinal  puncture, 
with  17  deaths — 39.5  per  cent.  In  19  cases  adrenalin  was  used  intraspinally, 
with  10  deaths — 52  per  cent.  In  4  cases  immune  serum  was  used  intra- 
spinally, with  2  deaths. 

The  opinion  of  the  visiting  and  resident  staff  was  definite  that  in  cases 
showing  serious  symptoms  better  results  were  obtained  from  the  use  of 
simple  puncture  (single  or  multiple)  than  when  puncture  was  followed  by 
the  administration  of  any  serum  or  medicament. 

Some  Hospital  Statistics. 

Following  is  a  table  showing  the  activities  of  the  Department  hospitals 
during  the  epidemic,  the  date  and  number  of  cases  first  admitted,  the  num- 
ber of  cases  discharged  with  and  without  visible  paralysis,  number  of  deaths 
and  mortahty  rates,  and  other  hospital  data : 


255 


Willard    Kingston  Queens- 

Parker       Avenue     Riverside      boro 
Hospital.    Hospital.    Hospital.  Hospital. 


Total. 


Date  first  case  was  admitted 6/28/16 

Admitted  :— 

Total  admissions  incl.  transfers.  2,078 

Largest  number  in  one  day 108 

Smallest  number  in  one  day....  1 

Number    cases    discharged 1,707 

Number   of   deaths 322 

Mortality    15.8 


6/20/16      6/30/16      7/18/16 


1,809 

1,211 

339 

5,427 

64 

66 

14 

1 

1 

1 

826 

1,064 

152 

3,749 

244 

110 

40 

716 

27.8 

9.3 

20.8 

16.0 

Duplicate  transfers  to  other  hospitals  and  cases  still  under  treatment 
account  for  the  discrepancy  between  the  total  of  4,475  deaths  and  cases 
discharged,  and  the  total  admissions  recorded,  5,427. 


Total. 


Willard  Kingston                       Queens- 
Parker  Avenue     Riverside       boro 
Hospital.  Hospital.    Hospital.  Hospital. 

Largest    number    in    hospital    at 

one  time  1,035  654             778             114 

Average  number  of  patients  per 

day    670  461             325               66 

Patient  days    78,609  46,259        48,835          8,975 

Average  days  per  patient 27.8  25.6            40.2            26. 

Cases  admitted  as  poliomyelitis, 

discharged  no  case 42  42               92                 5 

Cases     discharged     with     visible 

paralysis 1,065  684             665             112 

Cases  discharged  with  no  paraly- 
sis           642  142             399               40 


181—  4.9% 
2,526—67.4% 
1,223—32.6% 


The  largest  number  of  employees  at  one  time  in  the  hospitals  during 
the  epidemic  was  1,431,  including  doctors  83,  and  nurses  585. 

There  were  9,606  visits  made  by  parents  to  their  children,  and  2,008 
visits  made  by  private  physicians  to  patients  in  whom  they  were  interested. 

Of  1,707  cases  cared  for  continuously  in  the  Willard  Parker  Hospital, 
322  died,  or  15.8  per  cent. 

Of  1,064  cases  cared  for  continuously  in  the  Riverside  Hospital,  110 
died,  or  9.3  per  cent. 

Of  826  cases  cared  for  continuously  in  the  Kingston  Avenue  Hospital, 
244  died,  or  27.8  per  cent. 

Of  152  cases  cared  for  continuously  in  the  Queensboro  Hospital,  40 
died,  or  20.8  per  cent. 

The  higher  mortality  in  the  Kingston  Avenue  and  Queensboro  Hospitals 
is  to  be  explained  by  the  fact  that  the  acute  cases  progressing  toward  recov- 
ery were  frequently  transferred  to  the  Willard  Parker  and  Riverside  Hos- 
pitals, while  the  severe  cases,  which  were  too  ill  to  move,  or  which  died 


256 

shortly  after  admission,  were  retained  in  the  hospital  where  they  were  first 
admitted. 

Condition  of  Patient  on  Discharge  From  Department  Hospitals. 

List  of  poliomyelitis  cases  discharged  with  paralysis  (partial  and  com- 
plete) from  the  Department  Hospitals : 

Willard  Parker  Hospital  (1,065  cases)  : 

Involvement  of  lower  extremities  only 529 

Involvement  of  upper  extremities  only 104 

Involvement  of  head  and  neck 122 

Involvement  of  lower  and  upper  extremities Ill 

Involvement  of  back  and  lower  extremities 139 

Involvement  of  back  and  upper  extremities 12 

Involvement  of  face  with  upper  extremities 7 

Involvement  of  face  with  lower  extremities 19 

Involvement  of  back  only 20 

Kingston  Avenue  Hospital  (638  cases)  : 

Paralysis    (partial   and   complete)    of   group   of  muscles   and   special 
cases : 

Facial   102 

Neck 319 

Back   365 

Respiratory    108 

(Intercostal  and  Diaphragm) 

Both  upper  extremities 91 

Both  lower  extremities 358 

Right  upper  extremities 41 

Right  lower  extremities 45 

Left  upper  extremities 49 

Left  lower  extremities 52 

Strabismus    15 

Nystagmus 6 

Ptosis 3 

Bladder    1 1 

Esophageal  20 

Articulation  , 4 

Aphonia 6 

Ataxia   35 


257 

Riverside  Hospital  (665  cases)  : 

Face    29 

Face  and  trunk 8 

Face  and  rickets 6 

Lower  extremity  and  rickets 9 

Lower  extremity  and  upper  left  extremity 7 

Lower   right   extremity 24 

Lower  extremity  and  upper  right  extremity 3 

Lower  extremity,  neck  and  trunk 10 

Lower  extremity,  trunk  and  rickets 5 

Lower  right  extremity  and  rickets 4 

Lower  and  upper  left  extremities 1 

Lower  extremity  and  upper  trunk 6 

Lower  left  and  upper  right  extremities 15 

Lower  right  extremity 13 

Lower  left  extremity  and  rickets 6 

Lower  extremity  and  trunk 6 

Lower  left  extremity,  trunk  and  rickets 10 

Lower  extremity,  shoulder  and  neck 7 

Lower  left  extremity  and  trunk 1' 

Lower  right  extremity  and  trunk 2 

Lower  extremity  and  rickets 13 

Lower  extremity  and  face 2 

Lower  left  extremity  and  right,  neck  and  trunk 3 

Lower  left  and  right,  upper  left  and  right  extremities 6 

Lower  and  upper  right  extremities 12 

Lower  left  extremity  and  face 7 

Lower  extremity  and  trunk 12 

Lower  left  and  right  extremities  and  face 4 

Lower  left  extremity 48 

Lower  left  and  right  extremities  and  rickets 9 

Lower  left  extremity  and  neck 4 

Lower  left  extremity  and  trunk 4 

Lower  and  upper  left  extremities  and  trunk 3 

Lower  left  and  right  and  upper  right  extremities 7 

Lower  and  upper  left  extremities  and  neck 2 

Lower  extremity  and  shoulder 3 

Lower  extremity  and  face 10 

Lower  right  extremity  and  rickets 5 

Lower  left  extremity  and  rickets 15 

Lower  right  extremity  and  face 8 

Lower  right  and  upper  left  extremities  and  shoulder 7 

Lower  left  extremity,  face  and  trunk 7 


258 

Riverside  Hospital: 

Lower  right  extremity  and  trunk 13 

Lower  and  upper  left  extremities  and  face 5 

Lower  left  extremity  and  face 4 

Lower  left  and  right  extremities  and  rickets 5 

Lower  left  and  upper  right  extremities 36 

Lower  extremity 24 

Neck  and  trunk 6 

Neck    10 

Neck,  face  and  trunk 4 

Neck  and  trunk 1 

Rickets  14 

Trunk    23 

Trunk  and  rickets 2 

Trunk,   face  and  rickets - 4 

Upper  left  extremity 10 

Upper  right  extremity 9 

Upper  extremity   45 

Upper  and  lower  extremities 12 

Upper  extremity  and  face 8 

Upper  extremity  and  face 2 

Upper  left  and  right  extremities  and  face 1 

Upper  left  and  right  extremities 8 

Upper  right  extremity  and  trunk 2 

Upper  left  and  right  extremities,  lower  left  and  right  extremities 

and  trunk   7 

Upper  right  extremity  and  face 3 

Upper  and  lower  extremities  and  rickets 3 

Upper  and  lower  extremities,  trunk  and  rickets 4 

Upper  and  lower  extremities,  trunk  and  face 9 

Upper  left  extremity  and  trunk 6 

Upper  right  extremity .  .  9 

Upper  right  extremity  and  face 13 

For  further  details  and  charts  on  individual  special  cases,  many  of 
which  are  of  great  clinical  interest,  reference  must  be  made  direct  to  the 
histories  of  cases,  which  will  be  made  accessible  to  physicians  at  the  hos- 
pitals on  request. 

Visitors  to  Observe  Treatment. 

In  addition  to  a  number  of  prominent  executives  from  other  cities  and 
states,  as  well  as  the  Governor  of  Mississippi,  Sir  Henry  Burdett  of  London, 
England,  and  Dr.  Kuyea  of  Tokio  University,  Japan,  physicians  and  health 
officers,  to  the  number  of  821,  visited  the  hospitals  of  the  Department  of 


259 

Health  for  the  purpose  of  studying  the  diagnosis  and  treatment  of  the  dis- 
ease.    The  following  list  is  copied  from  the  visitors'  books  at  the  hospitals : 

Foreign  Countries: 

Cuba   6        Haiti   1 

China   1         \'ancouver    1 

United  States: 

Connecticut  13         Montana    3 

California 5         Nebraska    1 

Delaware    3         North  Carohna  12 

Florida    7         North  Dakota   3 

Georgia 3         New  Jersey   24 

Illinois   10         New  York  604 

Iowa   2         Oregon   1 

Indiana   4         Oklahoma    3 

Kentucky    2         Ohio    18 

Massachusetts    5         Pennsylvania   8 

Michigan 5         South  Carolina 15 

Minnesota 12         Texas    8 

Missouri  2         Tennessee 11 

Mississippi   4         Vermont 3 

Maryland   6        \\'est  Virginia 6 

Maine   3         Washington,  D.  C 6 

Newspaper  Representatives  Visit  Department  Hospitals. 

With  the  removal  of  hundreds  of  children  ill  with  poliomyelitis  to  the 
hospitals  of  the  Department  of  Health,  public  interest  naturally  centered  in 
the  conditions  obtaining  at  these  hospitals.  In  order  to  forestall  the  de- 
velopment of  any  prejudice  on  the  part  of  the  public  to  the  extensive  hos- 
pitalization of  cases  of  poliomyelitis  contemplated  by  the  Department  of 
Health  an  invitation  was  extended  to  the  newspaper  representatives  to  visit 
any  of  the  Department's  hospitals,  see  the  conditions  there  prevailing,  and 
report  fully  on  the  result  of  their  inspection.  For  a  similar  reason  facihties 
were  extended  to  the  representatives  of  several  newspapers  to  study  the 
work  of  the  inspectors  and  nurses  in  the  field,  and  particularly  the  work  ot 
the  ambulances  removing  patients  to  the  hospital.  These  invitations  were 
accepted  and  resulted  in  the  publication  of  full  descriptions  of  the  care 
given  to  the  patients  by  the  Department  of  Health.  This  frank  attitude  on 
the  part  of  the  Department  of  Health  served  to  inspire  public  confidence  and 
rendered  the  work  of  the  Department  less  difficult  than  it  otherwise  would 
have  been. 

Hospitalization  in  Other  City  Institutions. 
Early  in  July  it  became  apparent  that  the  epidemic  of  poliomyelitis 
was  progressing  at  such  a  rate  that  the  facilities  in  the  hospitals  of  the  De- 


260 

partment  of  Health  would  be  insufBcient  to  care  for  all  cases  requiring 
hospitalization.  As  many  as  sixty  to  one  hundred  and  ten  new  cases  were 
reported  daily,  and  from  fifty  to  sixty  per  cent,  of  these  had  to  be  removed 
for  treatment  to  the  hospitals  of  the  Department. 

A  plan  was  outlined  to  secure  the  services  of  private  hospitals  through- 
out the  city. 

It  was  decided  that  the  hospitals  of  the  Department  of  PubHc  Charities 
and  Bellevue  and  Allied  Hospitals,  as  well  as  private  hospitals  throughout 
the  city,  be  invited  to  co-operate  with  the  Department  of  Health;  and  on 
July  8th  the  Commissioner  of  Health  addressed  a  letter  to  the  superintend- 
ents of  most  of  the  large  private  hospitals  asking  if  the  hospitals  under  their 
jurisdiction  would  accept  cases  of  poliomyelitis. 

The  cost  of  caring  for  these  patients  would  be  borne  by  the  city,  and 
the  charges  were  to  be  made  upon  certification  by  the  Department  of  Health 
through  the  Department  of  Finance  on  the  special  emergency  funds  author- 
ized to  enable  the  Department  of  Health  to  cope  with  the  epidemic.  The 
rate,  per  case  per  day,  allowed  by  the  Comptroller,  was  $1.25.  This  rate 
had  been  the  standard  established  according  to  the  budget  of  the  city  for 
cases  assigned  by  the  Department  of  Public  Charities  to  institutions,  and  in 
estimating  the  service  rendered  to  the  community  by  the  private  hospitals, 
it  should  be  appreciated  that  this  rate  did  not  fully  compensate  the  hospitals 
for  the  care  given  to  the  patients.  The  same  rules  enforced  in  the  hospitals 
of  the  Department  of  Health  were  imposed  as  a  condition  on  the  private 
hospitals  in  caring  for  such  cases. 

A  daily  record  was  kept  of  new  cases  reported,  assignments  to  all  hos- 
pitals, transfers  from  all  hospitals,  number  of  cases,  and  available  vacancies 
in  all  hospitals. 

July  12th  was  the  first  day  on  which  this  work  was  undertaken,  and 
on  that  day  17  cases  were  sent  to  11  private  hospitals  and  22  cases  to  the 
hospitals  of  the  Department  of  Public  Charities  and  Bellevue  and  Allied 
Hospitals. 

In  order  to  avoid  difficulties,  cases  had  to  be  admitted  gradually  so 
that  on  an  average  of  one  hundred  new  cases  were  removed  to  these  private 
hospitals  each  week.  The  highest  number  of  cases  admitted  in  any  one 
day  was  recorded  on  August  28th,  when  the  census  of  the  private  hospitals 
showed  726  cases.  The  hospitals  of  the  Department  of  Public  Charities 
and  Bellevue  and  Allied  Hospitals  began  with  a  census  of  22  cases.  This 
was  increased  to  660  cases  on  August  20th.  The  hospital  on  Swinburne 
Island,  under  the  jurisdiction  of  the  Health  Officer  of  the  Port  of  New 
York,  came  to  the  assistance  of  the  Department  in  the  earlier  stages  of  the 
epidemic.  This  hospital  has  a  capacity  of  only  75  beds,  and  whenever  the 
cases  reached  that  figure,  twenty  to  twenty-five  of  the  oldest  cases  were 
transferred  to  a  hospital  of  the  Department  of  Health  so  as  to  make  room 
for  new  cases  only  from  the  Borough  of  Richmond  throughout  the  epidemic. 


261 

During  the  epidemic  an  effort  was  made  to  send  children  to  the  hos- 
pitals within  their  home  borough,  and  as  far  as  possible  nearest  to  their 
residence.  This  was  done  not  only  for  the  convenience  of  parents  in  visit- 
ing their  children,  but  to  reduce  the  danger  in  transporting  children  by 
ambulances  from  their  homes  to  the  hospitals. 

The  twenty-eight  hospitals  that  accepted  the  invitation  of  the  Com- 
missioner of  Health  are  listed  in  the  following  table : 

PRIVATE    HOSPITALS. 

Borough  of  Manhattan.  Borough  of  Brooklyn. 

N.  Y.  Throat,  Nose  and  Lung  Hos-  The  Long  Island  College  Hospital 

pital  Methodist  Episcopal  Hospital 

Babies'  Hospital  St.  Peter's  Hospital 

Presbyterian  Hospital  St.  Marv-'s  Hospital 

St.  Vincent's  Hospital  St.  Catherine's  Hospital 

N.    Y.    Orthopedic    Dispensar}'    and  German  Hospital 

Hospital 
Mt.  Sinai  Hospital 

Neurological  Institute  Borough  of  Queens. 

N.  Y.  Hospital  (59th  St.  Branch)  St.  John's  Hospital 
Flower  Hospital 

Borough  of  The  Bronx.  Borough  of  Richmond. 

Lincoln  Hospital  St.  Vincent's  Hospital  of  the  Bor- 
Lebanon  Hospital  ough  of  Richmond 

Montefiore  Home  Staten  Island  Hospital 
St.  Francis  Hospital 

PUBLIC   HOSPITALS. 

Borough  of  Manhattan.  Borough  of  Brooklyn. 

City  Hospital  Greenpoint  Hospital 

Metropolitan  Hospital  Kings  County  Hospital 

Bellevue  Hospital  " 

Borough  of  RicJunond. 
Swinburne  Island  Hospital 

The  Hospital  Situation  Month  by  Month. 
During  the  month  of  July,  of  a  total  of  3,409  patient-days,   service 
given  for  poliomyelitis  patients  in  20  to  27  hospitals  of  the  city : 

2,407  were  in  4  Health  Department  Hospitals 70% 

308  were  in  other  city  hospitals  ] 

577  were  in  private  hospitals  V 30% 

117  were  in  Swinburne  Island  Hospital   J 

During  the  month  of  August,  of  a  total  of  16,318  patient-days  in  28 
to  32  hospitals : 

10,591  w^ere  in  Health  Department  Hospitals 60% 

2,450  were  in  other  city  hospitals  1 

2,940  were  in  private  hospitals  \- 40% 

327  were  in  Swinburne  Island  Hospital  J 


'O 


262 

During  the  month  of  September,  of  a  total  of  12,476  patient-days  in  14 
to  32  hospitals : 

8,588  were  in  Health  Department  Hospitals 70% 

2,020  were  in  other  city  hospitals  1 

1,712  were  in  private  hospitals  ^ 30% 

156  were  in  Swinburne  Island  Hospital  J 

During  the  month  of  October,  of  a  total  of  4,753  patient-days  in  12  to 
17  hospitals: 

3,972  were'  in  Health  Department  Hospitals • .         80% 

540  were  in  other  city  hospitals  )  ^p.^ 

241  were  in  private  hospitals  C 

After  September  15th,  arrangements  were  made  with  the  private  hos- 
pitals, hospitals  of  the  Department  of  Public  Charities,  Bellevue  and  Allied 
Hospitals  and  the  hospital  on  Swinburne  Island  to  transfer  all  cases  to  the 
hospitals  of  the  Department  of  Health  where  the  census  of  poliomyelitis 
had  been  decreasing  for  a  week  or  more.  By  October  15th  these  transfers 
were  completed. 

The  weekly  removals  of  cases  to  all  hospitals  were  as  follows: 

July  12-18 447  cases,  a  daily  average  of  63 

July  19-25 557  cases,  a  daily  average  of  79 

July  26-31 •/ 693  cases,  a  daily  average  of  99 

Aug.    1-8  778  cases,  a  daily  average  of  1 1 1 

Aug.    9-15 710  cases,  a  daily  average  of  101 

Aug.  16-22 560  cases,  a  daily  average  of  80 

Aug.  23-29 417  cases,  a  daily  average  of  59 

Aug.  30-Sept.  5 256  cases,  a  daily  average  of  36 

Sept.     6-12 199  cases,  a  daily  average  of  28 

Sept.    13-19 135  cases,  a  daily  average  of  19 

Sept.  20-26 98  cases,  a  daily  average  of  14 

Sept.  27-Oct.  3 75  cases,  a  daily  average  of  10 

Oct.     4-10 54  cases,  a  daily  average  of  8 

Oct.   1 1-17 27  cases,  a  daily  average  of  4 

Oct.  25-31 18  cases,  a  daily  average  of  2 

SUMMARY. 

No    of         Patient 
Month.  Patients.  Days.  Cost. 

June 

July 

August    

September    

October   

- Total 2,125  37,630         $45,197  12 


4 

67 

$83  75 

524 

5.763 

7,153  75 

851 

18.841 

23,345  10 

676 

12,561 

14,117  52 

70 

398 

497  00 

263 


The  following  table  shows  the  number  of  cases  admitted  to  private 
hospitals  when  the  hospitals  of  the  Department  of  Health  were  overcrowded, 
and  the  cases  admitted  to  Department  and  City  hospitals : 


_  Date  Total 

First  Case       Cases 
Admitted.    Admitted. 


Trans- 
ferred to 
Total      Department 
Deaths.     Hospitals. 


Department  Hospitals — 

Willard   Parker    Tune  28 

Kingston   Avenue    June  20 

Riverside    June  30 

Queensboro    July    18 

City  Hospitals — 

Greenpoint    Julv    11 

City    July    22 

Kings  Count}-  July    12 

Metropolitan   July    19 

Bellevue    June  21 

Private  Hospitals — 

Long  Island   College  Hospital July    18 

N.  Y.  Nose  and  Lung  Hospital July    13 

Lincoln  Hospital  and  Home Juh'    12 

Babies'  Hospital June  25 

Lebanon    July    1 1 

Methodist  Episcopal  July    18 

Presbyterian    July    10 

St.  Francis   July    13 

St.  Vincent's    (^Manhattan) July    10 

N.  Y.  Orthopedic  Dispensary Jul}'    14 

Mt.  Sinai    June  17 

St.  Vincent's   (Richmond) July   27 

The  Neurological  Institute July   24 

St.  Mary's   July    16 

Staten  Island  Hospital July    27 

St.   John's    July    16 

St.  Catherine's    June     8 

N.  Y.  Hospital  (59th  Street  Branch)  . .  July    12 

Flower   Aug.     8 

German    (Brooklyn)     Aug.  23 

Montefiore  Home    Aug.  22 

Swinburne  Island    July    12 

Louise  Minturn    Aug.  16 

Herkimer   Sanitarium    Aug.  12 

St.  Peters  July    14 


2,077 

322 

1,795 

241 

1,206 

110 

347 

43 

5,425 

716 

43 

9 

64 

9 

103 

12 

419 

100 

202 

43 

831 

166 

7?) 

16 

4 

77 

18 

265 

58 

35 

i3 

6 

16 

1 

0 

0 

1 

16 

9 

2 

69 

13 

20 

29 

5 

50 

8 

58 

11 

\2> 

9 

3 

11 

2 

14 

4 

13 

1 

12 

1 

51 

9 

4 

51 

8 

41 

6 

32 

14 

11 

135 

20 

30 

75 

4 

12 

61 

6 

1 

1,201 

203 

146 

True  and  False  Cases  Admitted  to  Private  Hospitals. 
Of  1.809  cases  admitted  to  28  hospitals  in  the  city,  excluding  Depart- 
ment of  Health  hospitals,  1,780  were  designated  as  true  cases  of  polio- 
myehtis,  and  29  as  false  (or  L5  per  cent.)  ;  318  died,  giving  a  mortality 
of  17.5  per  cent;  278  cases  were  transferred  to  one  of  the  Department  of 
Health  hospitals  during  convalescence  to  make  room  for  additional  acute 
cases.  The  unusually  small  number  of  cases  designated  as  "  false "  is 
worthy  of  special  comment,  as  showing  the  accuracy  of  diagnosis  attained 
by  the  diagnostic  staff,  under  exceptional  and  trying  circumstances. 


CHAPTER   XII. 
A  Discussion  of  Treatment. 

1.     Special  Study  of  Serum  Treatment. 

In  the  treatment  of  the  acute  stages  of  poliomyelitis,  the  application  of 
immune  serum  from  human  beings  who  have  recovered  from  this  disease 
has  been  recommended  by  Netter(i),  who  used  such  serum  in  a  small 
series  of  cases.  Netter's  therapeutic  use  of  the  serum  was  suggested  by  the 
earher  work  of  Romer  and  Joseph (2),  Landsteiner  and  Levaditi(3),  and 
Flexner  and  Lewis  (^),  who  detected  neutralizing  immune  substances  in 
the  serum  of  monkeys  that  had  recovered  from  an  attack  of  poliomyelitis ; 
and  by  the  later  work  of  Levaditi  and  Netter(^),  and  Flexner  and  Lewis (*'), 
who  independently  showed  similar  immune  substances  in  the  serum  of 
convalescent  human  cases ;  also  by  the  subsequent  work  of  Flexner  and 
Lewis C^),  who  showed  that  the  immune  human  serum  had  the  power  of 
preventing  the  development  of  the  disease  in  monkeys,  when  injected  twenty- 
four  hours  after  the  intracerebral  inocculation  of  a  fatal  dose  of  virus. 

On  the  basis  of  these  results  the  work  with  immune  serum  was  taken 
up  at  the  Willard  Parker  Hospital,  at  the  Minturn  Hospital  and  in  the 
private  practice  of  a  number  of  physicians,  to  whom  the  serum  was  supplied 
for  treatment  of  suitable  cases.  It  was  soon  realized  that  the  cases  in  the 
pre-paralytic  stage  of  the  disease  would  be  the  most  suitable  for  serum  treat- 
ment, and  that  late  cases,  with  well  developed  paralysis  and  normal  tem- 
peratures, would  probably  not  be  influenced  by  the  administration  of  serum. 
The  serum  was  also  used,  however,  in  cases  where  the  temperature  was  still 
high,  the  paralysis  had  developed  in  some  parts  and  was  progressively  in- 
volving other  members  of  the  body. 

It  is  in  the  group  of  early  cases,  however,  treated  in  the  premonitory 
or  pre-paralytic  stage  of  the  disease,  where  we  can  obtain  very  much  more 


1.  Netter,  A. :  Serotherapie  de  la  poliomyelite  nos  resultats  chez  trente-deux 
malades  :  indications,  technique,  incidentes  possibles,  Bull,  de  I'Acad.  de  Med.,  Oct.  12, 
1915.  Netter,  A.,  and  Salanier,  M. :  Bull,  et  Mem.  See.  Med.  d.  Hop.  de  Paris,  March 
10,  1916. 

2.  Romer,  P.  H.,  and  Joseph,  K. :     Miinchen  Med.  Wchnschr.,  1910,  LVII,  568. 

3.  Levaditi  and  Landsteiner:     Compt.  Rend.  Soc.  de  Biol,  1910,  LXVIII,  311. 

4.  Flexner,  Simon,  and  Lewis,  P.  A. :  Experimental  Poliomyelitis  in  Monkeys, 
Seventh  Note,  The  Journal  A.  M.  A.,  May  28,  1910,  p.  1780. 

5.  Levaditi  and  Netter :     Presse  Med.,  1910,  XVIII,  268. 

6.  Flexner,  Simon,  and  Lewis,  P.  A.:     Seventh  Note  (footnote  2). 

7.  Flexner,  Simon,  and  Lewis,  P.  A. :  Experimental  Poliomyelitis  in  Monkeys, 
Eighth  Note,  The  Journal  A.  M.  A.,  Aug.  20,  1910,  p.  662. 


265 

tangible  results.     If  paralysis  develops  after  the  use  of  serum,  the  following 
points  should  be  noted : 

1.  The  number  of  doses  and  amount  of  serum  used  each  time. 

2.  The  group  to  which  the  serum  belonged. 

3.  The  number  of  days  the  patient  has  been  ill. 

4.  'The  number  of  hours  or  days  which  have  elapsed  since  the 
first  dose  of  serum  was  given. 

5.  The  degree  of  paralysis. 

6.  The  rapidity  with  which  the  paralytic  phenomena  begin  to 
clear  up. 

7 .  The  final  result ;  recovery,  paresis  or  paralysis,  stating  the 
actual  groups  of  muscles  affected. 

It  is  only  by  comparing  a  large  group  of  early  cases  treated  with  immune 
serum,  with  normal  human  serum,  and  with  no  serum  at  all,  that  we  shall 
be  able  to  arrive  at  any  certain  data  as  to  the  efficiency  of  the  serum 
treatment. 

To  help  in  the  diagnosis  of  early  cases  the  symptoms  and  findings  in 
the  spinal  fluid  are  of  value.  The  macroscopic  changes  in  the  spinal  fluid, 
already  described,  cannot  replace  the  more  careful  laboratory  examinations, 
but  are  found  to  be  of  great  service  clinically,  especially  where  immediate 
facilities  are  not  at  hand,  and  the  diagnosis  of  poliomyelitis  has  to  be  con- 
firmed for  purposes  of  isolation  and  treatment. 

Having  established  the  diagnosis  in  the  early  cases  by  clinical  symptoms 
and  examination  of  the  spinal  fluid,  the  next  step  is  to  inject  the  serum 
into  the  spinal  canal.  It  is  here  that  the  bedside  confirmation  of  the  diagnosis 
by  the  macroscopic  appearance  of  the  spinal  fluid  becomes  most  important. 
Where  the  spinal  fluid  indicates  the  presence  of  the  disease  on  macroscopic 
or  microscopic  observation  the  serum  can  be  promptly  administered  without 
any  further  delay  for  laboratory  examination  and  without  the  necessity  of 
another  lumbar  puncture,  although  the  confirmatory  laboratory  examination 
should  be  made  later. 

Fifteen  c.c.  of  the  serum  is  injected  by  the  gravity  method  after  the 
removal  of  a  slightly  larger  amount  of  spinal  fluid.  The  dose  is  repeated 
every  20-24  hours  until  two,  or  possibly  three,  injections  have  been  made. 
In  the  more  severe  cases,  especially  with  an  advancing  involvement  of  the 
respiratory  muscles,  the  serum  has  been  given  every  12  hours.  In  consider- 
ing the  frequency  of  the  repetition  of  the  dose,  and  especially  of  the  interval 
of  time  between  the  injections,  it  is  important  to  remember  what  is  taking 
place  in  the  cerebro-spinal  meninges  after  an  injection  of  the  serum.  A 
marked  polynuclear  cellular  reaction  is  produced,  which  probably  should  be 
given  time  to  exert  its  full  effect  before  the  spinal  canal  is  tapped  again 
and  the  rich  cellular  fluid  removed,  for  the  administration  of  a  second  or 
third  dose  of  serum.  If  the  reinjection  of  the  serum  is  delayed,  however, 
48  hours  or  longer,  there  will  be  noticed  a  rapid  clearing  up  of  the  arti- 
ficially produced  cellular  increase  in  the  spinal  fluid.  Considering  this 
therapy  as  a  possible  non-specific  cellular  stimulation  obtained  by  the  injec- 


266 

tion  of  a  rich  protein  fluid,  we  would  consider  that  an  interval  of  20-24 
hours  between  the  injections  is  best,  but  it  is  fair  to  state  that  in  three 
severe  cases  the  readministration  of  the  serum  was  made  every  12  hours 
with  apparently  good  results.  The  serum  is  rapidly  absorbed  from  the 
spinal  canal,  so  that  one  daily  repetition  of  the  dose  is  indicated,  especially 
if  the  efficiency  of  the  serum  is  considered  as  being  based  in  part  upon  its 
antibody  content. 

Source  of  Serum — Groups  of  immune  serum. 

The  immune  serum  used  in  the  treatment  of  cases  of  poliomyelitis  was 
obtained  from  convalescents  and  from  donors,  who  had  had  the  disease 
from  one  to  several  years  previously.  For  the  sake  of  accuracy,  and  to 
facilitate  the  proper  study  of  its  action,  the  serum  has  been  classified  into 
groups,  according  to  the  months  or  years  which  have  elapsed  since  the  im- 
mune donors  had  the  disease.  It  is  important  in  choosing  donors  for  im- 
mune serum  to  establish  the  fact  that  they  had  really  suffered  from  infantile 
paralysis,  and  not  to  accept  the  diagnosis  of  the  donor  on  his  word,  as  cases 
of  Bell's  palsy,  tuberculous  disease  of  the  bones  and  joints,  hemiplegias, 
syphilitic  and  otherwise,  will  frequently  be  found  among  so-called  "  immune 
donors." 

The  groups  into  which  the  serum  has  been  divided  are  as  .follows : 

Early  convalescent  serum from     2  to     6  months  after  an  attack 

Late  convalescent  serum from     6  to  12  months  after  an  attack 

Group  A  serum from     1  to     5  years  after  an  attack 

Group  B  serum from     5  to  15  years  after  an  attack 

Group  C  serum from  15  to  30  years  after  an  attack 

Group  D  serum from  30  years  up  after  an  attack 

Method  of  Obtaining  and  Preparing  the  Serum — 

(a)  Amount.  To'  obtain  the  immune  serum  the  blood  is  drawn 
from  suitable  donors  in  quantities  varying  with  the  age,  weight  and 
apparent  hemoglobin  content  of  the  individual.  On  an  average,  it 
is  safe  to  withdraw  2  oz.  from  children  9  to  10  years  of  age,  3  to  4 
oz.  from  children  12  to  13  years  of  age,  4  to  6  o'z.  from  individuals 
18  years  of  age  and  over.  Adults,  especially  robust,  full-blooded 
persons,  can  furnish  10  to  16  oz.  of  blood.  Similar  amounts  of  bloo'd 
can  be  safely  withdrawn  again  at  the  end  of  two  to  three  weeks. 

(b)  Technique  of  Obtaining  the  Blood.  The  blood  is  obtained 
either  by  means  of  a  No.  15  gauge  steel  or  platinum  needle,  to  which 
a  small  piece  of  rubber  tubing  is  attached.  In  children,  adults  and 
stout  individuals  with  small  or  indistinct  veins,  the  blood  is  withdrawn 
by  means  of  a  1-oz.  Record  Syringe  and  a  No.  17  gauge  needle.  The 
blood  is  collected  in  small  square  bottles  in  quantities  of  1  to  2  oz., 
and  given  a  long  slant  so  as  to  obtain  as  broad  a  surface  for  the 
separation  of  the  serum  as  is  possible. 

(c)  Preparation  of  the  Serum.  The  blood  is  allowed  to  clot, 
and  the  bottles  are  then  placed  in  the  ice-box  during  the  following 


267 

twenty-four  hours  to  allow  a  separation  of  the  serum.  This  is  de- 
canted the  following  day  and  centrifuged  to  free  it  from  pieceis  of 
blood  clot  and  red  blood  cells.  To  the  serum  is  next  added  a  pre- 
servative in  the  form  of  0.2  per  cent,  trikresol.*  This  is  added  in  a 
25  per  cent,  solution  in  quantities  o'f  4  c.c.  to  every  500  c.c.  of  serum. 
The  serum  is  then  allowed  to  remain  in  the  ice-box  for  forty-eight 
hours,  so  that  a  fine  precipitate,  which  forms  after  the  addition  of 
the  trikresol,  separates  out  and  is  removed.  The  serum  is  then  passed 
through  a  Berkefeld  stone  filter,  either  by  suction  or  pressure,  bottled 
in  quantities  of  15  c.c.  in  dark  amber  or  blue  bottles,  and  kept  cold 
in  the  ice-box. 

(d)  Duration  of  Efficiency  of  the  Serum.  If  the  serum  has 
been  preserved  with  trikresol,  or  handled  with  sterile  precautions  after 
it  has  been  passed  through  the  Berkefeld  filter,  and  is  afterward  kept 
in  a  cold  place,  it  will  probably  remain  efficient  in  its  specific  content 
for  a  number  of  weeks.  The  serum  obtained  was  used  up  almost  as 
fast  as  it  was  obtained.  Some  of  the  serum  which  was  kept  for  four 
to  six  weeks  seemed  to  be  as  active,  therapeutically,  as  the  more 
recently  drawn  serum. 

In  an  emergency,  or  where  the  facilities  for  treating  the  serum 
are  not  obtainable,  the  blood  is  simply  drawn  under  aseptic  conditions 
in  a  vessel  with  glass  beads  and  shaken  and  centrifuged ;  or  the  serum, 
drawn  in  the  usual  way,  is  allowed  to  separate  during  the  next  few 
hours,  and  promptly  used,  disregarding  entirely  the  presence  of  the 
few  suspended  red  blood  cells. 

If  a  further  experience  justifies  our  opinion  that  immune  serum  is 
beneficial,  it  will  probably  be  found  that  the  results  are  due  partly  to  specific 
immune  serum  and  partly  to  normal  human  serum  as  such.  If  this  con- 
clusion proves  to  be  true,  when  specific  immune  serum  is  not  obtainable,  it 
will  be  advisable  to  use  normal  human  serum,  when  possible,  which  can 
easily  be  obtained  from  parents  or  relatives  of  the  patient. 

It  is  important  to  note  that  in  the  preparation  of  serum,  either  for 
stock,  or  fresh  without  a  preservative,  no  heat  is  applied  either  for  inac- 
tivation  or  for  sterilization. 

Each  donor  should  be  otherwise  healthy  and  give  a  negative  Wasser- 
mann  reaction. 

Results  of  Serum  Treatment. 

The  most  evident  action  of  the  serum  is  a  marked  cellular  response 
of  the  cerebro-spinal  meninges  in  the  presence  of  the  serum  injected  by 
lumbar  puncture.  This  cellular  reaction  consists  of  a  very  decided  increase 
of  the  polynuclear  cells,  which  preponderate  in  some  of  the  cases  to  the 
extent  of  95  per  cent.,  while  the  total  cell  count  increases  from  500  to 
10,000  per  cubic  centimeter.  This  increase  of  cells  is  at  times  so  pro- 
nounced that  the  spinal  fluid  obtained  at  the  end  of  24  hours  has  a  very 
marked  turbid,  almost  purulent  appearance  and  a  heavy  sediment  of  cells 

*  The  trikresol  increases  the  local  irritant  action  of  the   serum,  and,  it  may  be 
found  advisable  not  to  add  it  as  a  preservative. 


268 

is  found  in  the  test  tube  within  a  few  hours  after  the  lumbar  puncture. 
Culturally,  these  fluids  are  always  sterile.  This  cellular  response  is  found 
also  after  the  injection  of  normal  human  serum,  of  normal  horse  serum 
and  of  the  secondary  albumoses  of  Jobling,  when  these  sera  are  used  in  the 
same  early  stages  of  disease.  This  high  reactivity  of  the  cerebro-spinal 
meninges  is  probably  due  to  the  very  marked  congestion  of  the  vessels  of  the 
pia-arachnoid,  and  of  the  cerebral  cortex.  It  is  probable  that  in  the  use  of 
immune  serum  we  have,  in  addition,  the  assistance  of  antibodies  against 
the  virus  of  poliomyelitis,  which  stimulate  the  polynuclear  cells  to  increased 
phagocytic  activity.  We  cannot  estimate  the  phagocytic  action  of  the  cells, 
as  the  virus  is  too  minute  to  be  seen.  It  must  not  be  overlooked,  however, 
that  we  have  probably  obtained  therapeutic  results  as  good  after  the  use  of 
serum  from  Group  C  or  Group  D  as  from  Group  A  or  B.  Such  sera  may 
have  only  a  problematic  value  as  antisera,  and  almost  their  entire  action 
may  depend  on  the  rich  protein  content  of  all  blood  sera.  Further  experi- 
mental work  will,  no  doubt,  have  to  be  carried  out  in  monkeys  to  determine 
whether  the  injection  of  immune  sera  into  the  spinal  canal  of  monkeys  will 
have  a  greater  protective  value  against  a  previous  infection  with  active 
virus  than  the  injection  of  normal  human  sera. 

If  the  injections  of  immune  or  normal  human  sera  are  made  in  the  later 
stages  of  the  disease,  when  the  temperature  has  already  subsided,  the  cellu- 
lar response  will  be  found  much  poorer,  and  only  an  opalescence  of  the 
spinal  fluid  will  be  noticeable  at  the  end  of  24  hours.  This  lessened  cellular 
response  is  probably  due  to  a  subsidence  of  the  acute  congestion  of  the 
brain  and  meninges. 

Clinically,  the  injection  of  immune  and  of  normal  human  serum  is  fol- 
lowed, within  24  hours  in  the  early  pre-paralytic  cases,  by  an  intensification 
of  the  meningeal  symptoms.  Increased  rigidity  of  the  neck,  opisthotonos, 
marked  Kernig,  hyper-irritability,  headache,  vomiting  and  increased  tem- 
perature, which  reaches  in  the  most  severe  reactions  up  to  104  or  105°  F. 
(See  chart  I,  page  269.)  At  times  where  the  reaction  is  especially  severe  we 
have  twitchings  or  even  convulsive  movements  of  the  extremities.  These 
symptoms  represent  merely  a  more  severe  degree  of  the  early  pre-paralytic 
phenomena  of  the  disease.  In  some  of  these  cases  the  temperature  is  simply 
caught  in  its  upward  rise  and,  therefore,  it  has  no  significance.  Definite 
temperature  reactions  have,  however,  been  noted  after  the  primary  and  also 
after  secondary  injections  of  serum.  The  typical  curve  can  be  seen  from 
the  following  chart :  A  rise  in  temperature,  persistence  for  another  24  hours, 
without  any  further  increase  after  a  second  dose  of  serum  and  subsidence 
by  a  rapid  lysis.     (See  chart  II,  page  271.) 

The  other  symptoms,  the  rigidity  of  the  neck  and  Kernig  persist  for 
two-three  days  after  the  temperature  has  dropped  to  normal.  Gradually 
the  symptoms  clear  up  and  the  patient,  if  there  is  no  complicating  paralysis, 
makes  a  rapid  and  uneventful  convalescence. 


Temperature  Chart  I. 


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Two  temperature  curves  in  cases  of  poliomyelitis  that  received  immune  serum. 
Figures  at  top  of  chart  indicate  duration  of  disease  smce  day  of  onset. 


273 

The  cases  treated  with  immune  serum  may  be  divided  into  three  groups 

1.  Cases  treated  at  the  Willard  Parker  Hospital. 

2.  Cases  treated  at  the  IMinturn  Hospital. 

3.  Cases  treated  with  other  physicians. 

I.     Willard  Parker  cases — 
A — Immune  serum  cases  : 

(a)  Pre-paralytic  cases. 

(b)  Paralytic  cases. 

(a)  Pre-paralytic  Cases — 25  Cases. 

Type  of  Serum.  Number  of  Doses. 

A    One   20 

B    1  Two   4 

C    17  Three    1 

D    7  - 

—  25 
25 

Results. 

(1)  Remained  free  from  paralysis 24 

(2)  Weakness  of  both  quadriceps  extensors 1 

(3)  Died 


25 
(b)   Paralytic  Cases — 88  Cases. 

(1)  Died ". 38 

(2)  Lived  50 

Of  the  38  who  died : 

18  died  in  less  than  24  hours  after  first  dose  of  serum, 

9  died  within  48  hours  after  first  dose  of  serum, 

5  died  in  more  than  48  hours  after  the  first  dose  of  serum, 

2  died  of  tubercular  meningitis, 
1  died  of  gastro-enteritis, 

3  died  of  pneumonia. 

Tj-pe  of  Case. 

Bulbar    7 

Bulbo-spinal    6 

Spinal    22 

Cerebral  1 

38           *Tuberculous    2 


Type  of   Serum. 

1 

4 

10 

23 

No.  of  Doses. 
One    

?^ 

A    

Two    

13 

B               

Three    

? 

C  

38 

Found  to  be  tuberculous  on  autopsy. 


38 


A  large  proportion  of  the  fatal  cases  were  children  in  the  last  stages 
of  an  advancing  Landry  type  of  poliomyelitis.  Of  the  18  that  died  within 
less  than  24  hours,  a  majority  were  moribund  cases  and  died  within  a  few 
hours  after  the  administration  of  a  single  dose  of  serum.     Many  of  the 


274 

patients  in  this  group  received  the  serum  only  as  a  last  resort.  The  bulbar 
cases  had  well-pronounced  respiratory  difficulty  before  the  serum  was 
injected. 

There  were  50  who  lived. 

Type  of   Serum.  No.  of  Doses.  Type  of  Case. 

Convalescent    1  One    39  Bulbar   8 

A    6  Two    9  Bulbo-Spinal    2 

B   21  Three    1  Spinal   40 

C    20  Four    1  Cerebral    

D    2  —  — 

—  50  50 
50 

These  cases  already  had  a  well-developed  paralysis  when  treated,  but 
were  in  a  still  active  stage  of  the  disease,  as  shown  by  temperature  and  a 
spreading  type  of  lesion.  These  children  recovered  and  showed  a  definite 
clinical  improvement.  It  is  impossible  to  determine  how  much  of  the  im- 
provement, which  is  also  generally  seen  in  the  untreated  cases,  was  due  to 
the  administration  of  the  serum  and  how  much  would  have  taken  place  dur- 
ing the  natural  course  of  the  disease. 

B — Normal  serum  cases. 

To  determine  whether  a  similar  cellular  reaction  would  be  produced 
by  the  intraspinous  injection  of  normal  serum  and  whether  similar  thera- 
peutic results  could  be  obtained,  a  series  of  pre-paralytic  and  paralytic  cases 
was  treated  with  serum  obtained  from  individuals  who,  to  their  knowledge, 
had  never  had  poliomyelitis.  It  is,  however,  recognized  that  persons  who 
have  never  shown  any  paralysis  may  have  protective  substances  in  their 
blood.     The  serum  was  used  in  the  following: 

(a)  Pre-paralytic  cases. 

(b)  Paralytic  cases. 

(a)  Pre-paralytic  Cases — 10  Cases. 

No.  of  Doses.  Results. 

One   7  Remained   free   from  paralysis 9 

Two    3  Developed   bulbar   symptoms   within   12  hours   and 

—  died    1 

10  _ 

10 
(b)  Paralytic  Cases — 33  Cases. 

(1)  Died 5 

(2)  Lived 28 

Of  the  5  who  died : 

3  died  within  less  than  24  hours  after  first  dose  of  serum, 

1  died  of  sepsis, 

1  died  of  pneumonia. 


No.  of  Doses. 

Type  of  Cases. 

One   

3 

Bulbar   

1 

Two    

3 

Spinal   

4 

275 

In  two  of  the  children  who  died  within  less  than  24  hours  the  disease 
was  of  the  advanced  ascending  spinal  form  of  the  Landry  type;  in  another 
it  was  of  the  bulbar  type. 

There  were  28  who  lived. 

No.  of  Doses.  Type   of   Cases. 

One   21  Bulbar    5 

Two   7  Spinal 23 

28  28 

There  was  a  distinct  clinical  improvement  in  the  cases  that  recovered, 
but  whether  more  than  would  naturally  take  place  without  the  use  of  serum 
cannot  be  properly  claimed. 

II.     Minturn  Hospital  Cases — 

These  can  also  be  divided  into  two  groups : 
a — Pre-paralytic  cases. 
b — Paralytic  cases. 

a.     Pre-paralytic  Cases — 15  Cases. 

Type  of  Serum.  No.  of  Doses. 

A    ...' One    

B   5  Two    11 

C   1  Three    2 

D    1  Four  2 

7  15 

Results. 

(1)  Remained  free  from  paralysis 9 

(2)  Developed  paralysis  within  less  than  24  hours 2 

(a)  Bulbar,  with  complete  recovery (B) 

(b)  Facial,  with  complete  recovery (C) 

(3)  Developed  paralysis  after  48  hours 4 

(a)  Facial  with  complete  recovery (B) 

(b)  Internal  strabismus  with  complete  recovery.  ...  (C) 

(c)  Both  lowers  and  left  deltoid,  with  marked  im- 
provement     (C) 

(d)  Both  lowers,  both  deltoids,  with  final  improve- 
ment     (C) 

This  series  represents  an  interesting  and  valuable  group  of  cases.  Each 
case  was  fully  treated  and  carefully  observed  for  a  period  of  8  wrecks,  and 
the  clinical  results  in  these  children  lead  one  to  the  conclusion  that  the 
serum  was  distinctl}^  beneficial  in  the  treatment  of  these  pre-paralytic  cases. 

b.     Paralytic  Cases — 18  Cases. 


A 

Type  of   Serum. 

3 
3 

12 

No.  of  Doses. 
One    

7 
7 
2 
2 

Type  of  Case. 
Bulbar   

2 

B 
C 
D 

Two    

Three  

Four    

Spinal    

16 
18 

18  18 


276 

Results. 

Recovered  with  improvement  of  paralysis 15 

Died  3 

( 1 )  Landry  s.pinal 2 

(2)  Bulbar   1 

The  cases  in  this  group  represent  mostly  the  usual  spinal  type  in  an 
active  stage  of  the  disease,  as  shown  by  the  short  history  and  the  presence 
of  temperature.  The  fatal  cases  were  seen  and  treated  at  a  time  when  the 
prognosis  seemed  to  be  very  doubtful. 

In  addition  to  the  serum  treated  cases  there  were  at  the  Minturn  Hos- 
pital 41  cases  that  received  no  serum.  The  majority  of  these  cases  came 
under  observation  during  the  stage  of  convalescence. 

III.    Cases  treated  with  other  physicians,  outside  of  Department  Hospitals — 
These  cases  were  personally  observed  and  treated. 

(a)  Pre-paralytic  cases. 

(b)  Paralytic  cases. 

(a)  Pre-Paralytic  Cases — 14  Cases. 
Died 0 


Type  of  Serum. 

No.  of  Doses, 

A 

3 

One   

7 

B  , 

2 

Two   

3 

C 

7 

Three    

4 

D  , 

2 

— 

—  14 

14 

Results. 

Remained  free  from  paralysis 11  cases 

Developed  paralysis 3  cases 

(1)  Facial  and  strabismus  with  complete  recovery (A) 

(2)  Anterior  tibial  groups  with  marked  improvement (D) 

(3)  Paresis  of  both  upper  eyelids  with  recovery (C) 

This  group  of  cases  treated  in  the  pre-paralytic  stage  of  the  disease  is 
also  interesting  in  the  large  number  of  complete  recoveries  that  followed  the 
treatment  with  immune  serum. 

(b)  Paralytic  Cases — 13  Cases. 

Type  of  Serum.  No.  of  Doses.  Type  of  Case. 

A    1      One   6     Bulbar   2 

B   3      Two    ■. .       2      Bulbo-spinal   1 

C    8      Three    5      Spinal   10 

D   1  -  - 

—  13  13 

13 

Results. 

Recovered  with  improvement  in  paralysis 9 

Died  4 

( 1 )  Landry  spinal 3 

(2)  Bulbar 1 


277 

The  bulbar  case  died  within  two  hours.  It  was  a  far  advanced  case 
and  the  prognosis  was  poor.  Of  the  three  Landry  spinal  cases,  two  died 
within  less  than  24  hours  after  treatment. 

In  addition  to  these  cases  that  were  seen  personally,  the  serum  was 
supplied  to  physicians  for  over  200  cases.  The  reports  obtained  from  the 
physicians  are  not  complete,  but  the  cases  reported  indicate  results  similar 
to  those  detailed  above. 

Control  Cases — 

It  is  very  difficult  indeed  to  state  definitely  to  what  extent  the  results 
obtained  with  serum  can  be  ascribed  to  the  action  of  the  serum  only,  both 
as  a  specific  and  non-specific  form  of  treatment.  As  stated  above,  the 
natural  course  of  the  disease  is  variable.  For  purposes  of  control,  there- 
fore, a  series  of  12  non-treated  pre-paralytic  cases  was  taken,  without  selec- 
tion, from  the  records  of  the  Willard  Parker  Hospital : 

Control  pre-paralytic  cases 12 

Remained  free  from  paralysis 5 

Developed  paralysis   7 

(a)  Bilateral  ptosis  with  little  movement  of  eyeballs. 

(b)  Complete  facial  paralysis. 

(c)  Paresis  of  right  arm  and  left  leg. 

(d)  Paresis  of  right  leg. 

(e)  Paresis  of  neck  muscles. 

(f)  Paresis  of  both  quadriceps  extensors. 

(g)  Paralysis  of  both  lower  extremeties. 

At  the  Minturn  Hospital  there  were  three  non-paralytic  cases  admitted 
8  days  after  the  onset  of  the  symptoms,  who  remained  free  from  paralysis. 
Of  two  pre-paralytic  cases,  one  developed  strabismus  and  one  paresis  of 
both  lov.'er  extremities. 


Summary  of  Cases  Treated  With   (A) — Immune  Human  Serum. 


Institution. 

Total. 

No  _ 
Paralysis. 

Paralysis  with 
Final  Recovery. 

Complete.    Partial. 

Died. 

I— Pre- 
paralytic. 

Willard  Parker  Hospital .  . 

Minturn  Hospital 

With  other  physicians .... 

Total 

.       25 
15 
14 

54 

24 

9 

11 

44 

3 
2 

5 

1 

3 

1 

5 

0 
0 
0 

0 

Institution. 

Total. 

Recovered. 

Compl 

ete. 

Partial. 

Died. 

II— Paralytic. 

Willard  Parker  Hospital . . 

Minturn  Hospital 

With  other  physicians .... 

Total 

88 
18 
13 

119 

5 
2 

1 

8 

45 

13 

8 

66 

38 
3 
4 

45 

278 


(B) — Normal  Human  Serum. 


Institution. 

Total. 

No  _ 
Paralysis. 

Paralysis  with 
Final  Recovery. 

Complete.    Partial. 

Died. 

I— Pre-             \ 

paralytic.     /Willard  Parker  Hospital .  . 

.      10 

9 

1 

Total. 

Recovered. 

Institution. 

Complete.             Partial. 

Died. 

II — Paralytic.  Willard  Parker  Hospital.. 

33 

4                        28 

5 

The  above  table  gives  a  summary  of  the  cases  treated  with  immune  and 
with  normal  human  serum.  It  is  interesting  to  see  that  of  54  pre-paralytic 
cases  treated  with  immune  serum  44  remained  free  from  paralysis,  while  of 
the  10  who  developed  some  form  of  paralysis,  5  made  a  complete  final  recov- 
ery. The  results  with  normal  serum  seem  to  be  favorable,  but  the  number 
of  cases  treated  i.n  the  pre-paralytic  stage  of  the  disease  is  too  small,  and  a 
larger  series  of  cases  should  first  be  treated  before  final  deductions  are  made. 
The  high  mortality  among  the  paralytic  cases  is  explained  by  the  desperate 
condition  of  many  of  the  patients  at  the  time  the  treatment  was  administered. 
The  ascending  Landry  type,  with  involvement  of  muscles  of  respiration,  or 
the  bulbar  cases,  with  involvement  of  the  respiratory  center,  made  up  the 
majority  of  the  fatal  cases.  Of  the  102  cases  that  lived,  12  recovered  com- 
pletely and  90  showed  improvement  at  the  time  of  discharge. 

Amount  of  Immune  and  Normal  Blood  Obtained  During  July^  August 

AND  September,  1916. 
Immune  Blood: 

(1)  Convalescent  blood    (early) 16  ounces 

(2)  Group  A  blood 77  ounces 

(3)  Group  B  blood 206  ounces 

(4)  Group  C  blood 643  ounces 

(5)  Group  D  blood 314  ounces 

Total  1 ,256  ounces 

Normal  Blood: 

14  Donors 144  ounces 

Summary  of  Results. 

It  is  known  that  in  poliomyelitis  we  have  a  group  of  non-paralytic  or 
abortive  cases  which  go  through  the  premonitory  symptoms,  but  do  not 
terminate  in  paralysis.     It  is  impossible  to  state,  therefore,  how  many  of 


279 

the  cases  treated  with  serum  would  have  remained  free  from  paralysis 
without  serum  treatment.  The  results  and  the  conclusions  from  any  form 
of  treatment  in  a  disease  which  is  so  varied,  variable  both  in  symptomatology 
and  in  prognosis,  as  to  life  and  as  to  function,  must  be  given  with  reserve. 

The  results  obtained  seemed  to  be  favorable  when  the  serum  was  used 
in  suitable  cases  in  the  pre-paralytic  stage  of  the  disease.  Paralysis  has  been 
followed  in  some  cases,  but  the  mortality  seems  to  have  been  influenced  by 
the  administration  of  serum. 

The  later  and  more  severe  cases  treated  after  the  paralysis  had  already 
made  a  distinct  headway  and  was  beginning  to  involve  the  muscles  of  respira- 
tion, showed,  in  a  certain  proportion  of  cases,  an  inhibitory  effect  of  the 
serum  upon  further  progress  and  a  possible  life  saving  result. 

While  no  absolute  judgment  of  the  value  of  a  serum  can  be  based  as 
yet  upon  the  results  obtained,  they  are,  nevertheless,  encouraging  and  justify 
a  continuation  of  the  serum  treatment  in  acute  poliomyelitis  until,  in  the 
course  of  time,  more  definite  data  be  available. 

Serum  Therapy  in  Experimental  Poliomyelitis. 

The  blood  of  persons  who  have  survived  an  attack  of  acute  poliomy- 
elitis contains  specific  substances  which  possess  the  ability  of  neutralizing 
active  poliomyelitis  virus.  This  has  been  demonstrated  by  Flexner  and 
Lewis,  Romer,  Landsteiner  and  Levaditi,  et  al.  It  has  also  been  shown 
that  monkeys  recovering  from  an  attack  of  poliomyelitis  become  refractory 
to  a  second  inoculation  of  virulent  material,  and  in  the  blood  of  these 
animals  can  be  demonstrated  the  neutralizing  principles  found  in  the  blood 
of  recovered  human  cases. 

Netter(i)  applied  this  knowledge  in  the  treatment  of  a  small  series 
of  human  cases,  with  perhaps  favorable  results.  His  conclusions  were  not 
very  definite.  He  administered,  intraspinally,  from  4  to  12  c.c.  of  serum 
obtained  from  a  recovered  case  whose  blood  yielded  a  negative  Wasser- 
mann.  It  was  administered  daily  for  four  or  five  days,  or  as  long  as  the 
clinical  symptoms  indicated  its  need.    One  case  received  eight  injections. 

Zingher(2)  treated  a  larger  number  of  cases  by  the  intraspinal  method, 
using  sera  obtained  both  from  recovered  cases  of  the  disease  and  from 
normal  persons.    His  report  is  favorable  to  the  treatment. 

No  tests  were  made  to  determine  whether  or  not  the  sera  obtained  from 
the  recovered  cases  possessed  the  neutralizing  powers  necessary  to  render  it 
specific.  Two  cases  of  reinfection  in  the  epidemic  of  the  past  summer  that 
had  come  to  our  attention  may  throw  some  doubt  on  the  assumption  that 
all  cases  that  recover  from  one  attack  of  the  disease  are  immune  to  a  second 
infection,  or  that  the  blood  of  all  such  cases  possesses  neutralizing  powers. 

However,  the  testing  of  the  serum  of  each  donor,  for  the  specific  prin- 
ciples would  render  the  whole  procedure  impracticable,  mainly  because  of 

(1)  Netter,  Bull,  de  I'Acad.  de  Med.,  1914,  IXVI,  p.  525. 

(2)  Zingher,  Journ.  Am.  Med.  Assn.,  March,  1917. 


280 

the  loss  of  time  necessary  to  perform  this  test,  and  aecondarily,  because  of 
the  expense,  for  at  the  present  time  there  is  no  way  of  demonstrating  this 
property  in  serum,  except  by  the  injection  into  a  monkey  of  active  virus  that 
had  been  placed  in  contact  with  the  serum.  From  a  practical  viewpoint  the 
probabilities  are  that  only  a  small  percentage  of  the  cases  would  give  a 
negative  test. 

Schwarz(^)  treated  21  cases  with  convalescent  human  serum.  Of 
these,  nine  recovered  without  paralysis.  Of  a  series  of  21  other  cases  treated 
expectantly  17  recovered  without  paralysis.  From  this  might  be  inferred 
that  the  serum  was  not  of  any  particular  advantage.  Schwarz  feels  that 
too  much  was  not  to  be  expected  of  the  use  of  the  immune  serum. 

Prognosis  in  poliomyelitis  is  a  very  difficult  matter.  It  will  require, 
therefore,  great  numbers  of  cases  adequately  controlled  to  gain  a  true  idea 
of  the  value  of  the  serum  treatment  from  the  clinical  viewpoint. 

The  clinical  use  of  the  serum  of  old  recovered  cases  of  poliomyelitis  is 
not  founded  on  complete,  clear-cut  animal  experimentation.  Its  use  is  in 
part  scientific  and  in  part  empirical. 

Flexner(*)  and  Lewis  performed  two  experiments,  the  results  of  which 
indicate  that  a  known  specific  serum  may  exert  a  prophylactic  effect.  An 
effective  dose  of-  active  serum  virus  was  injected  intracerebrally  into  a 
monkey.  Within  twenty-four  hours  after  the  inoculation,  and  daily  there- 
after, the  animal  received  intraspinal  injections  of  immune  serum  for  a 
number  of  days.  This  animal  remained  healthy,  whereas  the  control  died. 
Another  monkey  was  inoculated  by  intranasal  scarification  with  a  potent 
virus.  This  animal  received  intraspinal  injections  of  immune  serum,  within 
24  hours  after  the  inoculation,  and  at  three  day  intervals  for  a  number  of 
injections.  This  monkey  did  not  exhibit  any  symptoms  of  poliomyelitis, 
while  the  control  died  of  the  disease.  The  authors  state  that  if  the  amount 
of  virus  injected  is  not  in  excess  of  a  certain  amount,  the  procedure  de- 
scribed above  will  serve  to  protect  animals  injected  with  such  a  quantity  of 
virus. 

The  conditions  of  these  experiments,  however,  do  not  parallel  those 
which  are  met  with  when  dealing  with  actual  human  cases,  where  the  virus 
has  already  become  established  and  is  multiplying  in  the  central  nervous 
system,  as  evidenced  by  the  symptoms  of  the  disease.  In  this  instance,  the 
specific  serum  can  no  longer  prevent,  it  must  cure.  It  must  counteract  and 
nulHfy  virus  that  has  already  become  parasitic,  and  that  may  have  increased 
in  amount,  perhaps,  in  excess  of  that  which  can  be  taken  care  of  by  injections 
of  known  immune  serum. 

The  present  work  in  experimental  serum  therapy  was  undertaken  in  an 
attempt  to  supply  the  conditions  that  are  met  with  in  actual  practice.  This 
work  comprises  six  experiments,  in  each  of  which  were  used  two  animals. 
One  animal  was  serum  treated,  and  the  other  acted  as  control.     The  virus 

(3)  Schwarz,  Archives  of  Pediatrics,  Nov.,  1916,  Vol.  33,  No.  11,  p.  859. 

(4)  Flexner  and  Lewis,  Jr.,  of  A.  M,  A.,  May  28,  1910,  Aug.  20,  1910. 


281 

was  an  emulsion  of  brain  and  cord  material  derived  from  the  epidemic  of 
the  past  summer.  Virus  of  the  second  generation  was  used  in  the  first 
series,  and  the  virus  of  each  succeeding  generation  was  used  in  the  remain- 
ing experiments.  The  amount  of  virus  injected  was  not  determined  from 
very  much  previous  experience  with  this  strain.  That  the  dosage  was  not 
excessive  is  evidenced  by  the  fact  that  two  of  the  control  animals,  Nos.  37 
and  54,  and  Nos.  23  and  24,  not  used  in  these  experiments,  but  which  re- 
ceived the  same  amounts  of  virus,  survived  the  disease. 

The  serum  used  in  these  experiments  was  obtained  by  heart-puncture 
from  monkeys,  Nos.  98  and  102.  Both  of  these  animals  were  resistant  to 
the  effects  of  three  inoculations  of  brain  and  cord  material.  This  material 
was  inoculated  in  very  heavy  suspensions,  intracerebrally,  in  the  tissues  about 
the  sciatic  nerves  and  in  the  peritoneum.  The  material,  for  the  first  two 
inoculations,  was  obtained  from  two  human  cases,  clinically  and  pathologi- 
cally poliomyelitis.  The  third  inoculation  was  made  with  material  of  the 
second  generation  monkey  virus.  These  inoculations  were  given  three  weeks 
apart.  It  was  assumed  that  as  a  result  of,  these  three  inoculations,  these 
monkeys  were  immune  and  that  the  blood  of  these  animals  ought  to  contain 
the  specific  antibodies.  No  neutralization  test  was  performed  on  the  sera 
used  in  this  set  of  experiments.  This,  in  a  measure,  parallels  the  cHnical 
use  of  serum  by  Netter  and  Zingher. 

In  a  series  of  experiments  now  under  way,  we  shall  have  the  oppor- 
tunity of  observing  the  effects  of  known  monkey  and  human  immune  serum, 
in  the  experimental  serum  therapy  of  monkey  poliomyelitis. 

Method  of  Injection. 
The  serum  was  injected  by  syringe  in  doses  of  2  to  3^  c.  c,  depending 
upon  the  size  of  the  animal  and  resistance  offered  to  the  plunger  of  the 
syringe.  As  much  spinal  fluid  as  possible  was  withdrawn,  usually  with  the 
aid  of  the  syringe.  The  first  tap  yielded  up  to  2  c.  c.  of  slightly  turbid  fluid, 
but  subsequent  punctures  yielded  from  ^  to  1  c.  c.  of  fluid.  The  fluids,  on 
being  examined,  when  the  quantity  was  sufficient,  gave  a  globulin  test  and 
a  definite  increase  in  cells,  in  one  instance,  690  cells  per  cu.  mm.  The  serum, 
was  injected  very  slowly  and  with  extreme  caution  against  using  any  excess 
pressure.  Only  one  animal  exhibited  severe  efifects  after  the  intraspinal 
injection.  This  consisted  of  marked  rigidity  of  limbs,  retracted  neck  and 
labored  and  rapid  respiration.  These  symptoms,  however,  were  very  transi- 
ent and  within  half  hour  after  the  injection,  the  monkey  appeared  as  before 
the  injection.  Retraction  of  the  neck  was  noted  after  many  of  the  injec- 
tions, particularly  after  the  symptoms  of  paralysis  had  appeared. 

Time  of  Injection. 
The  time  periods  elapsing  between  the  injection  of  the  virus  and  the 
beginning  of  the  intraspinal  serum  injections  was  so  arranged  as  to  be  ap- 
plicable to  conditions  met  with  in  actual  practice.     In  the  Experiments  I 


282 

and  II,  the  serum  treatment  was  begun  on  the  first  day  of  the  appearance 
of  any  muscular  weakness.  In  the  remaining  four  experiments,  serum 
treatment  was  instituted  before  any  symptoms  had  appeared,  corresponding 
to  the  pre-paralytic  stage  in  the  human  disease. 

The  protocols  are  as  follows : 
Experiment  I. — 

Sept.  1,  1916.  Rhesus  No.  50.  Injected  with  ^  c.c.  intraspinally, 
2  c.c.  perisciatic  and  10  c.c.  intraperitoneally,  of  suspension  II.  gen. 
virus.  Rhesus  No.  51,  control,  received  1.2  c.c.  intracerebrally,  of 
the  same  emulsion.  Sept.  6,  1916,  No.  50  appeared  sick  and  limped 
on  left  leg.  Received  3j4  c.c.  serum  No.  102,  intraspinally.  Sept.  7, 
1916,  3^  c.c.  serum  No.  102,  intraspinally.  Limp  still  present.  On 
Sept.  10,  limp  was  not  noticeable  and  animal  appeared  strong  and 
healthy.  Sept.  5,  1916,  Rhesus  No.  51,  control,  exhibited  general 
tremors  and  marked  muscular  weakness.  No  definite  paralysis. 
Died  Sept.  8,  1916.  Congestion  of  the  pia  and  swelling  and  redden- 
ing of  gray  matter  of  cord.  The  virus  of  this  monkey  subsequently 
produced  typical  flaccid  paralysis. 

Whether  or  not  Rhesus  No.  50  really  had  poliomyelitis,  it  is 
difficult  to  jud^e.  He  did  not  at  any  time  present  frank  paralysis 
and  his  rather  rapid  recovery  is  suspicious.  This  animal  was  one  of 
whose  past  history  we  knew  nothing. 

Experiment  II. — 

Sept.  21,  1916.  Rhesus  No.  27,  ^^  c.c.  intracerebrally  and  2  c.c. 
perisciatic,  of  10  per  cent,  virus.  III.  gen.  Rhesus  No.  26,  control, 
3^  c.c.  intracerebrally,  s^me  virus. 

Sept.  28,  1916.  Rhesus  No.  27,  weakness  of  left  leg;  2j-'2  c.c. 
serum  No.  102,  intraspinally.  Rhesus  No.  26,  control,  paralysis  left 
and  weakness  right  leg. 

Sept.  29,  1916.  Rhesus  No.  27,  paralysis  both  legs,  weakness 
left  arm;  2^  c.c.  serum  No.  102,  intraspinally.  Rhesus  No.  26, 
paralysis  both  legs,  left  arm,  weakness  right  arm ;  difficulty  in 
breathing. 

Sept.  30,  1916.  Rhesus  No.  27,  complete  paralysis  of  limbs  and 
diaphragmatic  breathing.     Died. 

Rhesus  No.  26,  respiratory  failure.     Died. 
The  incubation  period  in  both  of  the  above  animals  was  eight  days  and 
duration  of  illness  three  days. 

Experiment  III. — 

Oct.  2,  1916.  Rhesus  No.  36,  ^2  c.c,  10  per  cent,  virus,  IV.  gen., 
intracerebrally.  Rhesus  No.  37,  control,  ^  c.c.  same  suspension, 
intracerebrall}^ 

Oct.  7,  1916.  Rhesus  No.  36,  apparently  normal ;  3  c.c.  serum 
No.  102,  intraspinally.    Rhesus  No.  37  well. 

Oct.  8,  1916.  Rhesus  No.  36  well ;  3  c.c.  serum  No.  102.  Rhesus 
No.  37  O.  K. 

Oct.  9,  1916.  Rhesus  No.  Z6,  paralysis  both  legs,  weakness  left 
arm ;  2^^  c.c.  serum  No.  102.  Rhesus  No.  37,  control,  paralysis  left 
leg.  weakness  right  leg. 


.283 

Oct.  10,  1916.  Rhesus  No.  36,  complete  paralysis  both  arms  and 
legs ;  breathing  with  difficulty ;  no  serum,  condition  bad.  Rhesus 
No.  Z7 ,  paralysis  both  legs,  weakness  left  arm.  Does  not  appear  as 
sick  as  No.  Zh. 

Oct.  12,  1916.  Rhesus  No.  36  died,  respiratory  paralysis.  Rhesus 
No.  Z7 ,  paralysis  both  legs,  weakness  left  arm.  Cessation  of  progress 
of  paralysis. 

Nov.  29,  1916.  Rhesus  No.  37  alive.  Permanent  paralysis  in 
legs.    Left  arm  O.  K. 

In  the  above  experiment,  Rhesus  No.  36  received  serum  treatment  on 
the  5th  day  after  injection  of  virus  and  two  days  before  the  onset  of 
paralysis.  Rhesus  No.  2i7  control,  exhibited  paralysis  on  the  same  day  as 
No.  36,  an  incubation  of  7  days.  The  serum  treatment  apparently  had  no 
influence  on  the  incubation  period.  Furthermore,  No.  36,  despite  three 
treatments,  suffered  a  rapidly  spreading  fatal  form  of  the  disease,  whereas 
No.  y? ,  control,  survived  the  same  injection,  but  with  residual  paralysis. 

Experiment  IV. — 

Oct.  13,  1916.  Rhesus  No.  43,  3^  c.c.  10  per  cent.  gen.  V.  virus, 
intracerebrally.  Rhesus  No.  42,  control,  very  large  animal,  1  c.c. 
intracerebrally  and  5  c.c.  intraperitoneally  of  same  virus. 

Oct.  18,  1916.  Rhesus  No.  43  received  intraspinally  3  c.c.  serum 
No.  102.  Oct.  21,  2>4  c.c.  serum  No.  98.  Oct.  22,  2  c.c.  serum  No.  98. 
No  signs  of  disease  during  this  period..  Rhesus  No.  42,  control,  pre- 
sented no  symptoms. 

Oct.  23,  1916.  Rhesus  No-  43,  left  leg  paralyzed  and  weakness 
in  right  leg ;  2  c.c.  serum  No.  98,  given  intraspinally.  Rhesus  No.  42 
shows  no  symptoms. 

Oct.  24,  1916.  Rhesus  No.  43,  paralysis  progressing;  2^  c.c. 
serum  No.  102  administered.    Rhesus  No.  42  apparently  well. 

Oct.  25,  1916.  Rhesus  No.  43,  paralysis  involving  both  arms 
and  legs ;  3  c.c.  serum  No.  102  given.  Rhesus  No.  42,  control,  shows 
weakness  in  left  leg. 

Oct.  27,  1916.  Rhesus,  No.  43  died  of  respiratory  paralysis. 
Rhesus  No.  42  presents  involvement  of  both  legs  and  weakness  of 
left  arm. 

Oct.  31,  1916.    Rhesus  No.  42  died  of  respiratory  paralysis. 

In  the  above  experiment,  the  serum-treated  animal  began  to  receive 
intraspinal  injections  of  serum  on  the  5th  day  after  the  injection  of  the 
virus  and  five  days  prior  to  the  appearance  of  symptoms  in  the  same  animal, 
and  7  days  before  the  control  animal  exhibited  muscular  weakness.  Fur- 
thermore, the  control  animal  had  several  times  the  dose  of  virus  received 
by  the  test  animal.  The  progress  of  the  disease  was  more  rapid  in  the 
serum  treated  animal,  which  terminated  on  the  5th  day  of  the  disease,  than 
in  the  control  animal,  which  died  on  the  7th  day  of  the  disease. 

Experiment  V. — 

Nov.  2,  1916.  Rhesus  No.  52,  >^  c.c.  of  10  per  cent.  VI.  gen. 
virus,  intracerebrally. 

Oct.  31,  1916.  Rhesus  No.  S,  large  animal,  control,  ;^  c.c.  intra- 
cerebrally and  5  c.c.  intraperitoneally,  of  10  per  cent.  VI.  gen.  virus 
used  on  No.  52. 


284 

Nov.  8,  1916.  Rhesus  No.  52,  apparently  normal,  received  2^ 
c.c.  serum  No.  102  intraspinally.  Rhesus  No.  S,  control,  showed 
paralysis  left  arm. 

Nov.  9,  1916.  Rhesus  No.  52,  paralysis  of  left  leg;  2^  c.c.  serum 
No.  102.  Rhesus  No.  S,  paralysis  of  all  limbs  and  respiratory 
paralysis.     Died. 

Nov.  10,  1916.  Rhesus  No.  52,  paralysis  progressing;  2^  c.c. 
serum  No.  102. 

Nov.  11,  1916.  Rhesus  No.  52,  paralysis  of  both  legs,  left  arm; 
2  c.c.  serum  No.  98  administered. 

Nov.  13,  1916.  Rhesus  No.  52,  complete  paralysis,  including 
muscles  of  respiration.    Died. 

Though  Rhesus  No.  52  received  a  smaller  dose  of  virus  and  one  injec- 
tion of  serum  on  the  sixth  day  after  the  inoculation,  the  incubation  period 
was  seven  days,  whereas  in  Rhesus  No.  S,  with  larger  dosage  and  no  serum 
therapy,  the  incubation  was  nine  days.  This  animal,  however,  suffered  a 
fulminating  type  of  disease,  dying  on  the  second  day  after  the  appearance 
of  symptoms.  This  was  probably  due  to  the  early  involvement  of  muscles 
of  respiration.  The  serum  treated  animal  died  on  the  fifth  day  of  the 
disease. 

Experiment  VI. — ^ 

Nov.  10,  1916.  Mangabey  No.  53,  yi  c.c.  5  per  cent.  VII.  gen. 
virus,  intracerebrally.  Mangabey  No.  54,  control,  1=2  cc.  5  per  cent, 
same  virus  intracerebrally. 

Nov.  15,  1916.  Mangabey  No.  53  appears  well;  3  c.c.  serum 
No.  102  intraspinally. 

Nov.  16,  1916.  Mangabey  No.  53,  3  c.c.  serum  No.  102 ;  appears 
normal. 

Nov.  17,  1916.    Mangabey  No.  53,  paralysis  of  left  leg;  no  serum. 

Nov.  18,  1916.  Mangabey  No.  53,  paralysis  progressing;  2^  c.c. 
serum  No.  98.    Mangabey  No.  54,  weakness  left  leg. 

Nov.  19,  1916.  Mangabey  No.  53,  paralysis  both  legs  and  left 
arm ;  2  c.c.  serum  No.  98  administered.  Mangabey  No.  54,  marked 
weakness  in  left  leg  and  slight  weakness  in  right  leg;  progress  of 
paralysis  slow. 

Nov.  20,  1916.  Mangabey  No.  53  lies  prone,  does  not  stir  body, 
moves  right  arm  weakly ;  tremor  of  head.  Mangabey  No.  54,  con- 
dition about  the  same. 

Nov.  22,  1916.  Mangabey  No.  53,  complete  paralysis ;  died. 
Mangabey  No.  54,  weakness  in  legs  more  marked. 

Nov.  25,  1916.  Mangabey  No.  54,  progress  of  involvement 
slow;  shows  slight  weakness  of  left  arm;  tremor  of  head. 

Nov.  27,  1916.  Mangabey  No.  54  shows  signs  of  improvement ; 
left  arm  apparently  stronger,  as  is  also  the  right  leg. 

Dec.  1,  1916.  Mangabey  No.  54,  improvement  marked;  feeds 
well;  can  sit  up  without  great  difficulty;  will  probably  recover. 

In  the  foregoing  experiment,  the  test  animal  received  serum  treatment 
on  the  fifth  day  after  the  injection  of  virus  and  two  days  before  symptoms 
of  the  disease  appeared  in  an  incubation  of  seven  days.     The  disease  ran 


285 

a  progressive  fatal  course  despite  four  injections  of  serum.  The  control 
animal  showed  evidence  of  paralysis  on  the  eighth  day  after  infection, 
with  slowly  progressing  symptoms  and  with  subsequent  improvement.  This 
animal  is  alive  at  this  writing. 

Summary. 
The  summary  of  the  results  of  the  foregoing  experiments  is  as  follows : 
Five  of  the  six  serum  treated  animals  died,  a  mortality  of  83  per  cent. 
Four  of  the  six  control  animals  died,  a  mortality  of  66  per  cent. 

Of  the  four  animals  that  received  intraspinal  serum  therapy  before 
the  appearance  of  paralysis,  one  received  1  treatment,  two  2  treatments 
and  one  5  treatments  in  the  pre-paralytic  stage.  In  one  of  these  the  incuba- 
tion period  was  the  same  as  in  the  control  animal.  In  the  remaining  three, 
the  incubation  was  shorter  by  one  to  two  days  than  in  the  control  animals. 
The  duration  of  the  disease  in  the  serum  treated  animals  was  somewhat 
shorter  than  in  the  controls,  varying  from  two  to  six  days,  whereas  in  the 
latter  the  acute  progressive  stage  was  from  three  to  eight  days,  indicating 
a  greater  rapidity  in  the  spread  of  the  disease  in  the  central  nervous  system. 
The  number  of  serum  administrations  varied  from  two  to  eight,  depending 
upon  the  condition  of  the  animal.  They  were  discontinued  when  the  animal 
exhibited  distinct  signs  of  improvement,  or  when  the  paralysis  had 
progressed  to  respiratory  difficulty. 

Discussion. 

Experimental  poliomyelitis  is  several  times  more  fatal  a  disease  than 
human  poliomyelitis,  and  perhaps  it  is  rather  severe  on  the  clinical  use  of 
unknown  "  immune  "  serum  to  compare  it  with  experimental  use  of  a  like 
serum  in  monkey  poliomyelitis.  However,  that  seems  to  be  the  only  method 
known  at  the  present  time  of  gaining  any  correct  idea  of  the  value  of  this 
method  of  treatment.  An  effort  was  made  in  the  foregoing  experiments  to 
parallel  clinical  conditions.  Two  of  the  animals  were  injected  with  serum 
on  the  first  day  of  the  appearance  of  paralysis  and  four  from  five  to  six 
days  after  date  of  infection,  but  in  the  pre-paralytic  stage.  The  test  animals 
were  controlled  by  six  animals  that  received  no  serum  therapy. 

Comparison  of  effects  of  the  disease  in  the  serum  treated  animals  as 
against  the  effects  observed  in  the  control  animals,  would  incline  one  to  the 
inference  that,  at  least  in  the  experimental  disease,  intraspinal  injections 
of  serum  are  not  only  of  no  value,  but  also  that  there  may  be  in  them  an 
element  of  harm. 

The  mechanism  producing  the  untoward  effects  has  not  been  demon- 
strated, but  it  may  consist  in  the  exaggeration  of  the  pathological  process 
already  existing  by  the  introduction  into  the  subdural  space  of  a  foreign 
substance.  Marked  meningeal  symptoms  have  been  observed  following  the 
introduction  of  serum,  both  in  the  experimental  and  human  disease.  In 
some  instances  the  spinal  fluids  obtained  after  the  injection  of  serum  have 


286 

shown  distinct  evidence  of  accentuated  inflammatory  reaction,  as  indicated 
by  increased  morbidity,  due  to  increase  of  cellular  elements ;  increase  in  the 
content  of  albumin  and  globulin. 

That  this  meningeal  reaction  may  have  a  deleterious  influence  on  the 
already  existing  pathologic  process  in  the  cord  and  brain  proper  is  not 
without  plausibility. 

Careful  comparative  study  of  the  nervous  tissues  of  the  serum  treated 
and  the  control  animals  may  indicate  whether  or  not  this  is  the  true 
explanation. 

In  the  minds  of  the  general  public  and  of  most  physicians,  there  exists 
a  close  analogy  between  the  use  of  serum  in  epidemic  meningitis  and  in 
poliomyelitis,  and  its  success  in  the  former  has  influenced  them  to  have 
faith  in  the  success  of  the  latter.  The  pathology  of  the  two  conditions, 
however,  is  quite  different.  In  acute  purulent  meningitis  the  process  is 
limited  almost  entirely  to  the  meninges,  the  brain  and  cord  substance  being 
little  if  at  all  involved,  though  there  may  be  some  secondary  congestions. 
In  poliomyelitis  the  pathological  picture  is  reversed.  Here  the  brain  and 
cord  substance  is  mainly  involved,  whereas  the  inflammation  in  the  meninges 
is  entirely  secondary.  Injecting  a  foreign  substance  into  the  slightly  in- 
flamed meninges  sets  up  in  most  cases  an  acute  aseptic  meningitis,  as  is 
shown  by  changes  in  the  spinal  fluid,  and  clinically,  by  increased  tempera- 
ture, rigidity  of  the  neck  and  other  signs  of  meningeal  irritation.  It  is 
reasonable  that  this  increased  inflammatory  reaction  should  tend  to  accentu- 
ate the  inflammatory  changes  existing  in  the  subjacent  substance  of  the 
brain  and  cord.  This  is  contrary  to  the  commonly  accepted  idea  that  the 
first  indication  in  the  treatment  of  an  inflammation  is  rest.  And  that  this 
reaction  may  be  harmful  is  borne  out  by  the  results  of  animal  experimenta- 
tion. In  meningitis,  on  the  other  hand,  the  injection  of  serum  into  actively 
inflamed  meninges  is  not  followed  by  an  increase  in  the  inflammatory 
reaction,  as  is  evidenced  by  the  clearing  up  of  the  fluid  and  the  amelioration 
of  the  clinical  symptoms  in  favorable  cases. 

It  would  seem,  therefore,  that  from  this  point  of  view  the  action  of 
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power,  this  would  have  to  be  exerted  very  speedily,  since  the  damage  is  so 
often  done  within  48  or  72  hours  after  the  onset  of  symptoms. 


287 


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2.     Orthopedic  Treatment, 

In  the  orthopedic  treatment  of  poHomyehtis  at  the  Willard  Parker 
Hospital  it  was  found  best  to  allow  all  cases  to  remain  undisturbed  in  bed 
during  the  presence  of  acute  symptoms,  as  fever,  pain,  etc.  At  the  end 
of  this  time,  usually  about  one  week,  each  case  was  carefully  examined  by 
the  attending  orthopedic  surgeon  to  determine  the  extent  of  the  paralysis 
and  to  decide  upon  the  best  means  of  supporting  the  involved  muscles,  to 
relieve  strain,  and  to  prevent  deformity. 

For  cases  with  involvement  of  neck  and  back  muscles  and  those  with 
the  more  marked  meningeal  symptoms,  a  frame  bent  to  coincide  with  the 
contour  of  the  back  was  found  most  effectual  for  relieving  the  strain  on 
the  muscles  and  also  alleviating  the  pain,  which  was  often  very  severe.  For 
involvement  of  neck  muscles,  a  light  plaster  collar  with  sometimes  a  hood 
attachment  was  applied.  Plaster  casts  and  moulded  plaster  splints  were 
applied  to  paralyzed  extremities.  All  forms  of  support  were  removed  at 
frequent  intervals  to  enable  the  patient  to  practice  voluntary  movements, 
to  preserve  joints,  and  to  guard  against  decubitus,  which  was  apt  to  occur 
very  quickly  in  the  more  severely  ill  cases.  It  was  interesting  to  note  that 
many  very  fretful  children  immediately  became  quiet  and  contented  when 
proper  support  was  supplied. 

During  the  fifth  week  all  patients  with  paralysis  still  present  were  care- 
fully examined  with  a  view  of  determining  the  best  form  of  future  treat- 
ment.    We  attempted  to  classify  them  as  follows : 

Those  patients  with  extensive  paralysis  who  are  unable  to  hold 
the  body  erect  and  for  whom  any  immediate  form  of  ambu- 
latory treatment  is  impossible 6  cases 

Patients  with   slight  paralysis  or  weakness  in  whose  muscles 

power  is  rapidly  returning 1443  cases 

Patients  whose  paralyzed  muscles  apparently  do  not  exhibit  any 
sign  of  returning  power  and  the  paralysis  might  be  consid- 
ered more  or  less  permanent 9  cases 

Patients  with  marked  paralysis  but  with  some  returning  power, 
in  which  recovery  would  probably  take  months  or  a  year 
or  two  249  cases 

Patients  in  group  one  were  discharged  with  plaster  supports.  It  was 
recommended  that  these  patients  receive  continued  hospital  care  if  possible. 

Group  two  patients  were  discharged  with  plaster  splints  if  necessary 
and  were  referred  to  a  neighboring  clinic  for  continued  supervision. 

-Patients  in  group  three  were  carefully  fitted  with  braces  with  lock 
joints,  etc.,  and  crutches  if  necessary. 

Those  in  group  four  were  fitted  with  a  less  expensive  but  suitable 
type  of  brace,  as  it  was  thought  probable  that  the  brace  would  be  unneces- 
sary after  a  few  months. 


289 

Children  under  one  year  of  age  were  discharged  with  Hght  plaster  sup- 
ports. 

A  few  adults  who  might  be  classified  in  group  one  were  equipped  with 
braces  and  crutches  to  enable  them  to  stand  up  and  perhaps  take  a  few 
steps,  but  more  especially  to  obviate  possible  domestic  difficulties  and  to 
prevent,  if  possible,  that  condition  of  mind  so  frequent  in  those  hopelessly 
bedridden. 

The  paralysis  about  the  shoulder  seemed  slowest  to  improve.  For 
these  cases  a  brace  which  would  hold  the  arm  at  right  angles  to  the  body 
was  prescribed.  A  short  leg  brace  with  a  stop  to  prevent  foot-drop  was 
used  in  cases  of  paralysis  of  the  anterior  tibial  group,  or  the  stop  was 
reversed  when  the  posterior  tibial  group  was  involved,  or  a  double  stop 
when  both  groups  were  involved,  a  straight  brace  extending  up  the  thigh, 
allowing  no  motion  at  the  knee,  was  used  when  the  flexors  or  extensors  of 
the  leg  are  involved.  For  cases  in  group  three  this  brace,  with  a  movable 
joint  which  locks  in  extension,  was  used.  Those  cases  with  involvement  of 
the  rotators  of  the  thigh,  and  muscles  about  hip- joint,  were  equipped  with  a 
brace  extending  up  to  the  pelvis  and  having  a  pelvic  band.  The  motion  in 
this  brace  at  the  hip  is  adjusted  to  the  requirements  of  the  case.  If  both 
lowers  are  involved  a  double  brace  may  be  used.  These  cases  were  also 
equipped  with  crutches  if  necessary. 

It  has  been  observed  in  numerous  instances  that  the  paralysis  has 
greatly  improved  as  soon  as  the  patient  has  gotten  up  and  about  with  the 
brace.  This  is  well  shown  by  the  large  numbers  of  cases  in  which  it  has 
been  possible  to  cut  down  the  brace,  lessening  the  number  of  muscles  sup- 
ported by  it  or,  as  in  many  cases,  to  entirely  dispense  with  the  brace.  We 
believe  that  the  effort  to  maintain  equilibrium  and  to  get  about  supplies  a 
stimulus  such  as  no  other  method  of  treatment  can  supply  to  the  nerve 
centers,  nerves,  and  muscles,  and  possibly  facilitate  the  opening  of  new 
paths  for  the  transference  of  motor  and  trophic  impulses  to  the  muscles. 

The  patients  to  whom  we  have  supplied  braces  are  being  visited  at 
their  homes,  to  make  sure  that  the  brace  is  being  properly  worn  and  that 
instructions  as  to  bathing,  exercise  and  massage  are  properly  carried  out. 


CHAPTER    XIII. 
Prophylaxis. 

Poliomyelitis  being  an  acute  infectious  disease,  it  follows  as  a  logical 
consequence  that  the  same  sanitary  measures  must  be  employed,  and  the 
same  regulations  enforced,  for  the  prevention  of  its  spread  as  for  the  pre- 
vention of  any  other  acute  infectious  or  communicable  disease,  isolation, 
disinfection,  etc.  It  is  obvious  from  what  is  known  of  the  nature  of  the 
infection,  that  segregation  and  other  similar  measures  approaching  complete 
control,  must  be  impracticable,  as  segregation  to  be  effective  in  poliomyelitis 
must  include  not  only  paralytic,  but  also  non-paralytic  or  abortive  cases, 
and  the  healthy  carriers  of  the  virus ;  nor  is  there  any  specific  antitoxin  or 
protective  vaccine  against  the  disease  upon  which  we  can  rely  for  the  im- 
munization of  exposed  susceptible?. 

Under  these  circumstances,  as  soon  as  the  Department  of  Health  real- 
ized that  it  was  facing  an  outbreak  of  poliomyelitis,  it  took  steps  to  pro- 
vide for  the  enforcement  of  the  necessary  general  sanitary  measures  for 
the  prevention  of  its  spread. 

The  first  step  toward  the  attainment  of  this  object  was,  primarily,  to 
enlist  the  co-operation  of  the  medical  profession  in  the  work  that  had  to  be 
performed ;  secondly,  to  instruct  the  public  as  to  the  reasons  for  the  necessity 
of  its  performance.  For  this  purpose,  in  addition  to  the  exaction  of  the 
usual  requirement  that  all  recognized  and  suspected  cases  of  the  disease 
be  promptly  reported,  there  was  issued,  early  in  July,  a  circular  of  "  Infor- 
mation for  Physicians  Regarding  Poliomyelitis  (Infantile  Paralysis),"  stat- 
ing what  was  known  concerning  the  causes,  modes  of  infection,  transmis- 
sion and  symptoms  of  the  malady,  and  giving  directions  as  to  the  general 
care  of  the  patients.  Later,  there  was  issued  another  circular  of  "  Informa- 
tion for  the  Public  Regarding  Infantile  Paralysis  (Poliomyelitis),"  describ- 
ing in  simple,  non-technical  language  the  early  symptoms  of  the  disease  and 
its  communicability  through  the  discharges  of  the  nose,  throat  and  bowels 
of  those  ill  with  the  disease  to  well  persons,  and  laying  especial  stress  upon 
its  transmissibility  by  means  of  non-paralytic  cases  and  healthy  persons 
from  sick  persons  with  whom  they  were  associated.  Instructions  were  also 
given  how  to  guard  against  the  disease,  what  to  do  in  cases  of  sickness 
and  what  the  Health  Department  would  do.  A  copy  of  these  circulars  and 
other  special  information  regarding  procedure  in  poliomyelitis  regulations 
governing  quarantine,  removal,  care  and  treatment  of  persons  sufifering 
from  the  disease,  etc.,  issued  by  the  Department  of  Health,  will  be  found 
in  the  appendix. 

These  procedures  for  the  prevention  of  the  spread  of  infection  were 
strictly  enforced  and  1;he  physicians  of  the  city,  appreciating  the  situation, 
willingly  lent  their  aid  toward  the  support  of  the  health  authorities. 


5,208 

2,975 

.57 

2,382 

1,345 

.56 

529 

248 

.46 

136 

46 

.33 

50 

18 

.36 

291 

To  cite  an  instance  of  this  support  in  the  matter  of  reporting  cases : 
From  August  5th  to  December  16lh,  1916,  inclusive,  a  record  was  kept  by 
the  Department  of  all  the  field  assignments  given  inspectors  for  investiga- 
tion of  reports  from  all  sources,  of  poliomyelitis  or  suspected  poliomyelitis 
cases,  together  with  the  number  found  by  diagnosticians  to  be  true  cases. 
This  record  shows  that  as  the  epidemic  advanced  the  percentage  of  true 
poliomyelitis  cases  to  assignments  perceptibly  diminished;  in  other  words, 
that  an  increasing  number  of  suspected  cases  were  reported  by  physicians 
as  their  knowledge  and  interest  grew  with  the  extent  of  the  epidemic. 

The  figures  given  below  include  all  cases  reported  from  August  5th  to 
December  16th,  with  the  exception  of  one  week  in  August,  for  which  the 
data  are  not  available : 

Percentage  of  True  Poliomyelitis  to  Inspections. 

Assignments.  True  Cases.     Percentage. 

August    (from    5th) , 

September    

October    

November    

December    

Total 8,305  4,632  .55 

During  the  epidemic,  including  a  period  of  sixteen  weeks,  whenever  a 
case  of  poliomyelitis  was  reported  a  careful  survey  was  made  of  every 
stable  within  a  radius  of  four  blocks.  In  these  stables,  when  an  insanitary 
condition  was  found,  frequent  reinspections  were  made  until  the  nuisances 
were  abated.  Thus  a  total  number  of  10,996  inspections  were  made  in  5,142 
stables ;  unclean  stalls,  runways,  floors,  ceilings  and  walls  were  carefully 
inspected,  manure  removed,  yards  cleaned,  etc. 

The  street  car  lines  were  inspected  and  orders  issued  to  have  the  cars 
cleansed  carefully  and  thoroughly  at  least  once  a  day  and  maintained  in  a 
cleanly  condition  at  all  times. 

The  food  stores  in  the  city  and  the  various  places  where  food  is  kept 
or  handled,  were  carefully  inspected  and  special  provision  was  made  to 
insure  the  sanitary  condition  of  all  foods  and  drinks  distributed  during  the 
epidemic. 

As  a  result  of  this  active  and  vigorous  work  for  health  and  cleanliness, 
on  the  part  of  the  health  authorities,  and  especially  because  of  th,e  campaign 
of  publicity  and  education  conducted  through  the  Department's  Bureau  of 
Public  Health  Education,  the  whole  city  was  aroused  to  interested  participa- 
tion in  the  work  of  sanitation.  It  was  observed  by  everyone  acquainted 
with  ordinary  conditions  that  the  city  was  never  before  so  clean ;  that  tene- 
ment houses  were  never  so  clean ;  parents  were  never  so  careful  about  their 
children,   food  was  never  so  generally  kept  covered  and  kept  clean,   and 


292 

sound  medical  advice  was  never  so  eagerly  sought  or  so  well  followed. 
Moreover,  sanitary  regulations  were  never  so  easily  enforced  as  during  the 
epidemic.  The  violations  that  occurred  were  due  mainly  to  oversight  and 
not  to  indifference  or  wilful  disobedience. 

Nor  were  other  organizations  behindhand  in  furthering  the  work  of 
sanitation.  Invaluable  aid  was  rendered  by  practically  all  the  other  municipal 
departments,  and  by  many  private  associations.  The  streets  were  flushed 
daily,  tenement  houses  were  inspected  and  violations  of  the  law  directed  and 
remedied.  Hospital  care  was  provided  for  thousands  of  patients — ^besides 
the  large  number  of  cases  treated  in  the  Department  of  Health  hospitals, 
many  additional  cases  were  admitted  to  28  or  30  other  hospitals  in  the 
city.  Automobiles  and  ambulances  were  turned  over  to  the  Health  Depart- 
ment to  use  for  this  work.  Orders  for  large  amounts  of  printing  were  hur- 
ried through.  Funds  were  provided  and  additional  physicians,  laboratory 
workers,  nurses,  domestics  and  others  were  employed.  A  host  of  volunteers 
aided  in  the  distribution  of  health  leaflets;  and  press  and  pulpit  zealously 
joined  in  preaching  the  propaganda  of  prophylaxis.  Altogether  the  com- 
munity set  an  example  of  co-operation  for  health  and  civic  betterment  which 
deserves  the  highest  commendation. 

This  work  of  co-operative  sanitation,  instigated  by  the  stimulus  of  a 
dreaded  disaster,  not  only  succeeded  in  checking  the  visible  calamity,  but  it 
produced  an  unseen  and  unexpected  result  which  was  even  more  remarkable 
in  its  effects.  Notwithstanding  the  prevalence  of  the  epidemic  of  polio- 
myelitis— a  disease  which  fatally  affects  young  children  in  particular,  80  per 
cent,  of  those  attacked  dying  from  it  in  the  first  five  years  of  life — both  the 
tnfant  mortality  and  the  general  death  rates  of  the  city  were  as  low  or  lower^ 
throughout  the  summer  of  1916,  than  they  were  during  the  same  period 
of  1915,  when  there  was  no  epidemic  to  contend  with.  The  table  (p.  295) 
giving  the  official  mortality  statistics  for  the  City  of  New  York,  for  1915 
and  1916,  demonstrates  these  remarkable  results  in  figures  that  cannot  be 
controverted. 

Commentary  is  unnecessary  with  such  facts  as  these  to  prove  the 
efficacy  of  co-operative  sanitation  in  public  health  work.  Unfortunate  as 
the  recent  epidemic  undoubtedly  was,  and  in  some  respects  unproductive 
from  an  epideniiological  point  of  view,  this  disastrous  visitation  may  yet 
turn  out  to  have  been  a  blessing  in  disguise,  if  it  fixes  indelibly  in  our  minds 
one  obvious  and  incontestable  truth — that  the  control  not  only  of  polio- 
myelitis, but  of  all  preventable  diseases,  does  not  depend  upon  the  mysterious 
power  of  any  supernatural  agency,  but  that  the  remedy  lies  largely  within 
ourselves. 

"  Our  remedies  oft  in  ourselves  do  lie. 
Which  we  ascribe  to  heaven :  the  fated  sky 
Gives  us  free  scope ;   only  doth  backward  pull 
Our  slow  designs,  when  we  ourselves  are  dull." 


293 


APPENDIX. 

Names  of   Members  of   Committees  in   Connection  with  Poliomyelitis 

Epidemic. 

Committee  on  Infantile  Paralysis — Advisory  Council. 


Dr.  Louis  C.  Ager,  Chairman.* 
Dr.  Elias  H.  Bartley. 
Dr.  Robert  O.  Brockway. 
Dr.  Eugene  S.  Dalton. 
Dr.  Thurston  H.  Dexter. 
Dr.  A.  H.  Doty. 
Dr.  George  Draper. 


Representatives 

of  the 

Department  of  Heakh. 


Dr.  Simon  Flexner.* 
Dr.  Royal  S.  Haynes. 
Dr.  Henry  Koplik. 
Dr.  Howard  Mason. 
Dr.  Herman  Schwarz.* 
Dr.  J.  T.  Simmonson. 
Dr.  Rudolph  F.  Rabe. 
rDr.  S.  J.  Baker. 
Dr.  J.  S.  Billings. 
Dr.  S.  R.  Blatteis. 
Dr.  Charles  F.    Bolduan.* 
Dr.  George  L.  Nicholas. 
Dr.  W.  H.  Park. 
Dr.  B.  S.  Waters. 
Dr.  R.  J.  Wilson. 


Mayor's  Committee  on  the  Epidemic  of  Poliomyelitis  (to  Act  as  His 
Advisers  During  the  Epidemic). 


Dr.  E.  H.  Bartley. 

Dr.  John  W.  Brannan. 

Dr.  Leland  E.  Cofer., 

Dr.  H.  B.  Delatour.  • 

Dr.  A.  H.  Doty 

Dr.  George  Draper 

Dr.  Simon  Flexner. 

Dr.  S.  S.  Goldwater. 


Dr.  Henry  Koplik 

Dr.  Samuel  Lambert 

Dr.  C.  H.  Lavinder 

Dr.  LeonLouria 

Dr.  William  H.  Park 

Dr.  Antonio  Stella 

Dr.  J.  M.  Van  Cott 

Dr.  Philip  Van  Ingen 


Dr.  Walter  B.  James 


Committee  on  Research  on  Poliomyelitis. 


Dr.  H.  L.  Amoss. 
Dr.  George  Draper. 
Dr.  W.  H.  Frost. 


Dr.  Josephine  B.  Neal. 
Dr.  William  H.  Park. 
Dr.  Hans  Zinsser. 
Dr.  C.  H.  Lavinder. 


*  These  had  been  members  of  the  Collective  Investigation  Committee  which  studied 
the  1907  epidemic. 


294 

Orthopedists  Connected  With  D&partment  of  Health  Hospitals. 

Dr.  A.  H.  Cilley Riverside  Hospital. 

Dr.  J.  J.  Nutt Willard  Parker  Hospital. 

Dr.  Henry  Ling  Taylor.  .  Queensboro  Hospital  and  Swinburne  Island. 
Dr.  D.  Truslow Kingston  Avenue  Hospital. 

Committee  on  Permanent  Relief  and  Follozv-up  Care. 

Miss  Bessie  Amerman,  Henry  Street  Settlement. 

Dr.  Oliver  Bartine,  Hospital  for  Ruptured  and  Crippled. 

Dr.  Henry  W.  Frauenthal,  Dispensary  and  Hospital  for  Joint  Diseases. 

Miss  Jessie  M.  Hixon,  Association  for  Improving  the  Condition  of  the 
Poor,  Brooklyn. 

Dr.  John  R.  Howard,  Jr.,  N.  Y.  Orthopedic  Dispensary  and  Hospital. 

Miss  Bessie  LeLacheur,  Association  for  Improving  the  Condition  of  the 
Poor,  Manhattan. 

Dr.  Thomas  J.  Riley,  Brooklyn  Bureau  of  Charities. 

Dr.  Jacques  C.  Rushmore,  Long  Island  College  Hospital. 

Dr.  Reginald  H.  Sayre,  Attending  Orthopedist,  Bellevue  Hospital. 

Dr.  J.  D.  Steinhardt,  Bronx  Hospital  and  Dispensary. 

Dr.  Walter  Truslow,  Kingston  Avenue  Hospital. 

Dr.  Morris  D.  Waldman,  United  Hebrew  Charities. 

Dr.  Donald  E.  Baxter,  Director  of  Committee. 

Committee  on  House  to  House  Visits. 

ORGANIZATIONS   REPRESENTED. 

Associated  Charities  of  Flushing. 

Brooklyn  Association  for  Improving  the  Condition  of  the  Poor. 

Brooklyn  Bureau  of  Charities. 

Charity  Organization  Society  of  New  York. 

Henry  Street  Settlement. 

Metropolitan  Life  Insurance  Company. 

New  York  Association  for  Improving  the  Condition  of  the  Poor. 

United  Hebrew  Charities  of  New  York. 

United  Jewish  Aid  Society  of  Brooklyn. 

University  Settlement  Society. 


295 


Death  Rates  by  Months  at  All  Ages  and  Under  One  Year  of  Age. 
City  of  New  York— 1915  and  1916. 

1915^  T916^  ~ 

Death  Rate  Death  Rate 

Rate                          Under  Rate                          Under 

Per        Deaths       1  Year  Per  Deaths       1  Year 

Deaths.                          1000        Under        of  Age  1000  Under        of  Age 

All        Popula-    1  Year     Per  1000         All  Popula-  1  Year     Per  1000 

Causes.       tion.       of  Age.       Births.       Causes.  tion.  of  Age.       Births. 

January....  6,872  14.81  1,160  93^8  7,966  16.75  1,106  98^5 

February...  6,126  14.61  1,008  89.9  6,723  15.11  1,054  91.8 

March 7,462  16.08  1,231  93.4  7,077  14.88  1,126  90.3 

April 7,681  17.10  1,239  102.0  6,791  14.75  1,082  97.0 

May 6,625  14.27  1,191  107.4  6,661  14.00  1,086  96.1 

June 5,862  13.04  1,052  88.1  5,723  12.43  881  78.8 

July 5,818  12.54  1,201  105.6  6,209  13.05  1,072  96.3 

August 6,011  12.95  1,598  130.9  7,011  14.75  1,614  131.1 

September.  .  5,543  12.34  1,326  114.2  5,578  12.12  1,098  99.8 

October 5,582  12.03  1,032  91.3  5,605  11.78  889  75.8 

November.  .  5,562  12.38  855  78.6  5,792  12.58  887  80.4 

December. .  .  7,049  15.19  973  81.3  6,665  14.01  923  79.1 

Year...    76.193        13.93      13,866  98.2        77,801        13.88      12,818  93.1 

Some  References  Consulted. 

V.  Heine :  Beobachtungen  ueber  Laehmungszustaende  der  unteren 
Extremitaete  und  derer  Behandlung.  Stuttgart,  1840.  Spinale  Kinder- 
laehmung,  1860. 

M.  P.  Jacobi :  Pathology  of  Infantile  Paralysis.  American  Journal  of 
Obstetrics,  Vol.  7,  p.  1,  1874. 

O.  Medin :  Kliniske  og  Epidemioliske  Undersoeglser  over  der  Akute 
Poliomyelit  i  Norge.  Vidensk.  Selsk.  Skr.  Christiana,  1909. 

Ed.  Mueller:     Die  Spinale  Kinderlaehmung,  Berlin,  1910. 

Wickman :  Acute  Poliomyelitis  (Heine-Medin's  Disease).  Tr.  Ma- 
loney.     Jour,  of  Nerv.  and  Ment.  Dis.,  Monograph  Series  No.  15,  1913. 

Warner:     Die  Heine-Medin  Krankheit,  Leipzig,  Diss.  Halle,  1913. 

Collective  Investigation  Committee :  Report  on  the  New  York  Epi- 
demic of  1917.  Jour,  of  Nerv.  and  Ment.  Dis.,  Monograph  Series  No.  6,  1910. 

Frost :     Hyg.  Lab.  Bull.  No.  90,  Washington,  D  C. 

Frauenthal  &  Manning:     A  Manual  of  Infantile  Paralysis,  1914. 

Lovett:     The  Treatment  of  Infantile  Paralysis,  Philadelphia,  1916. 

Harbitz  &  Scheel:  Pathologish-anatomische  Untersuchungen  ueber 
Akute  Poliomyelitis  and  Verwandter  Krankheiten  von  der  Epidemien  in 
Norwegen,  1903-1906.     Vidensk.  Selsk.  Skr.  Christiana,  1907. 

Peabody,  Draper  and  Dochez:     Rockefeller  Institute,  New  York,  1912. 

Landsteiner  and  Popper:     Ztschr.  f.  Immunitaetsforsch.  11,  1909. 

Leiner  and  Weisner :     Wien,  Klin.  Wochschr.  XXII,  1909. 

Landsteiner  and  Levaditi :  Compt.  Rend.  Soc.  Biol.,  LXII  and  LXVII. 

Flexner  and  Lewis :  Jour.  Amer.  Med.  Assoc,  1909 ;  also  1910  and  1913. 

Flexner  and  Noguchi :     Jour.  Exp.  Med.,  XVIII,  1913  and  1914. 

Netter:     Bull.  del'Acad.  de  Med.,  LXVI,  1914. 

Rosenow,  Towne  and  Wheeler:  Jour.  Amer.  Med.  Assoc,  LXVII,  1916. 


296 

Regulations,  Leaflets,  Circulars  and  Bulletins  Issued  by  the  Department 

of  Health. 

(Regulations.) 

Regulation  1.  Incubation  period. — The  incubation  period  of  the  dis- 
ease and  the  quarantine  period  of  children  under  sixteen  (16)  years  of  age 
who  have  been,  but  no  longer  are,  exposed  to  infection  shall  be  fourteen 
(14)  days. 

Regulation  2.  Quarantine. — In  all  families  where  a  case  of  Poliomyeli- 
tis has  occurred,  all  the  children  under  sixteen  (16)  years  (except  those 
who  have  had  the  disease),  shall  be  quarantined  in  the  home  until  two  (2) 
weeks  after  the  termination  of  the  case  by  death,  removal,  or  recovery.  The 
patient  whether  at  home  or  in  a  hospital  shall  be  quarantined  for  six  (6) 
weeks  from  the  date  of  the  onset  of  the  disease.  No  case  in  a  hospital  shall 
be  returned  home  until  the  quarantine  is  ended. 

Regulation  3.  Placards. — All  premises  where  a  case  of  Poliomyelitis 
occurs  shall  be  placarded ;  the  only  exceptions  being  hotels  and  boarding 
houses,  which  shall  not  be  placarded  provided  the  patient  is  at  once  re- 
moved to  the  hospital,  the  room  or  rooms  occupied  by  the  patient  immedi- 
ately renovated  in  accordance  with  the  requirements  of  the  Bureau  of  Pre- 
ventable Diseases,  and  no  quarantined  children  remain  on  the  premises.  In 
private  houses,  one  placard  shall  be  affixed  to  the  door  entering  the  room 
the  patient  occupies.  In  apartment  and  tenement  houses,  one  placard  shall 
be  affixed  to  the  door  of  the  apartment  occupied  by  the  patient.  All  such 
placards  shall  be  dated  and  initialed  by  the  representative  of  the  Depart- 
ment who  affixes  the  placards  in  accordance  with  the  provisions  of  this 
Regulation  and  shall  remain  so  affixed  until  the  quarantine  is  terminated 
and  the  renovation  completed.  (As  amended  by  the  Board  of  Health,  Sep- 
tember 26,  1916.) 

Regulation  4.  Removal  to  Hospital — No  case  shall  be  left  at  home 
unless  the  following  conditions  are  complied  with : 

a.  There  must  be  a  physician  in  daily  attendance. 

b.  The  patient  must  have  a  special  attendant  who  must  obey 
the  quarantine  Regulations  and  must  not  do  any  housework,  market- 
ing, or  perform  any  household  duties  for  other  members  of  the 
family.  He  or  she  may,  however,  leave  the  house,  provided  the  neces- 
sary precautions  as  to  personal  disinfection,  etc.,  are  observed,  and 
contact  with  all  children  should  be  avoided. 

c.  The  patient  and  the  attendant  must  have  a  room  or  rooms 
separate  from  the  rooms  of  others  in  the  family. 

d.  All  the  windows  of  this  room  must  be  screened  and  all  flies 
in  the  room  killed. 

e.  The  family  must  have  a  separate  toilet  for  its  exclusive  use. 
/.     Quarantine   Regulations   must  be   strictly   observed   by   the 

patient  and  the  other  children  of  the  family,  if  any.  When  the  disease 
occurs  in  the  premises  of  families  of  food  handlers,  the  employment 
of  such  person  or  persons  at  this  occupation  is  forbidden,  unless  they 


297 

occupy  entirely  separate  apartments  for  a  period  of  two  weeks  after 
the  removal,  recovery,  or  death  of  the  patient. 

g.  The  personal  and  bed  linen  of  the  patient  must  be  properly 
disinfected  and,  after  removal,  recovery  or  death  of  the  patient,  com- 
plete renovation  of  the  room  or  rooms  occupied  by  the  patient  and 
atendant  shall  be  required. 

Regulation  5.  Visitors  to  Hospitals. — Each  case  may  be  visited  twice 
during  its  stay  in  the  ho'spital,  by  a  parent  or  guardian.  If  the  child  is  criti- 
cally ill,  the  guardian  or  parent  will  be  notified  and  will  be  permitted  to 
visit  daily,  while  child  is  dangerously  ill.  Information  relative  to  condition 
is  given  out  at  the  Information  Desk  in  each  hospital,  or  by  telephone  in 
response  to  telephone  inquiry  from  the  parent  or  guardian. 

Regulation  6.  Certificates  for  children  leaving  the  ciiy. — The  Depart- 
ment of  Health  of  the  City  of  New  York  does  not  require  certificates  of 
anyone  leaving  or  entering  the  City.  It  issues  certificates  only  as  a  con- 
venience and  aid  to  persons  leaving  the  City.  None  are  issued  to  persons 
passing  through  the  City. 

Such  certificates  state  that  the  persons  or  family  therein  named  have 
not  resided  in  a  house  where  a  case  of  Poliomyelitis  has  occurred.  The 
applicant  must  sign  a  request  for  the  certificate.  They  are  refused  to  per- 
sons who  live  in  a  house  where  a  case  of  Infantile  Paralysis  has  occurred, 
or  who  present  symptoms  of  the  said  disease. 

The  certificates  are  good  only  until  midnight  of  the  following  day, 
except  when  issued  on  a  Saturday  or  on  the  day  preceding  a  holiday,  when 
they  are  good  until  midnight  of  the  second  following  day. 

Regulation  7.  Return  of  cases  of  Poliomyelitis  to  Nezv  York  City. — 
Cases  of  Poliomyelitis  occurring  in  residents  of  New  York  City  who  are 
temporarily  residing  outside  the  City,  and  developing  within  two  (2)  weeks 
of  the  time  of  leaving  the  City,  shall  be  permitted  to  return,  provided : 
(a)  a  private  conveyance  (private  car,  private  automobile,  carriage  or 
ambulance)  is  used,  and  (b)  the  patient  goes  direct  to  a  hospital  authorized 
by  the  Department  of  Health  to  care  for  cases  of  Poliomyelitis. 

Cases  in  which  the  onset  of  the  disease  occurs  two  weeks  or  more  after 
leaving  the  City,  may  not  return  to  New  York  City  until  eight  weeks  from 
the  date  of  onset  of  the  disease.  But  in  special  cases,  where  proper  medi- 
cal, surgical  and-  nursing  care  is  not  obtainable,  patients  may  be  brought 
back  to  the  City  in  a  private  conveyance,  provided  they  go  directly  to  a 
private  hospital  authorized  by  the  Department  of  Health  to  receive  cases 
of  Poliomyelitis. 

Regulation  8.  Return  of  children  who  have  been  exposed  to  Polio- 
myelitis to  Nezv  York  City. — Children  under  sixteen  (16)  outside  of  New- 
York  City  who  have  been  exposed  to  infection  with  Poliomyelitis  within 
two  weeks,  may  return  to  the  City  under  the  following  conditions : 

a.  They  must  come  by  private  conveyance  and  must  go  direct 
to  their  homes. 


298 

b.  Advance  notice  must  be  sent,  and  authorization  obtained,  by 
telephone,  by  the  local  Health  Ofificer.  Such  notice  must  give  the 
name  and  age  of  each  child,  together  with  the  identified  address, 
including  the  floor,  and  the  latest  date  of  exposure  to  infection,  and 
must  be  followed  immediately  by  a  written  notice. 

c.  Such  children  shall  be  promptly  visited  at  their  homes  by  a 
representative  of  the  Department  of  Health  and  instructed  as  to 
nature  and  duration  of  quarantine.  They  must  not  leave  the  premises 
until  two  weeks  have  elapsed  from  the  date  of  last  exposure  to  infec- 
tion. 

d.  The  premises  shall  not  be  placarded,  but  the  children  shall  be 
visited  at  regular  intervals,  and  should  quarantine  be  violated  the 
parents  or  guardians  shall  be  summoned  to  Court  and  fined. 


(Procedures.) 

Duties  of  Inspectors. — Cases  reported  by  physicians,  nurses,  social 
workers  and  other  citizens  shall  be  visited  at  once  by  Inspector,  whether 
such  report  requests  removal  of  the  case  to  a  hospital  or  not.  Attending 
physicians  to  the  Department  of  Health  hospitals,  however,  may  admit  cases 
direct  without  Inspectors'  visits. 

The  janitor  of  the  building  in  which  a  case  of  Poliomyelitis  occurs,  or 
his  or  her  representative,  shall  be  seen  in  every  instance  by  the  Inspector 
and  notified  that  he  or  she  will  be  held  personally  responsible  by  the  De- 
partment of  Health  for  failure  to  report  any  breach  of  the  quarantine  Regu- 
lations or  the  removal  or  defacement  of  the  placards  placed  on  the  building. 

If  the  Inspector  makes  or  confirms  the  diagnosis  of  Poliomyelitis,  the 
Borough  Office  of  the  Department  shall  be  notified.  Such  Borough  Office 
shall,  if  removal  of  patient  is  recommended,  summon  an  ambulance.  In 
every  case  the  Inspector  shall  leave  with  the  person  in  charge  or  control  of 
the  patient  a  hospital  admission  slip  or  card,  properly  and  fully  filled  out 
and  signed.  Where  a  case  is  permitted  to  remain  at  home,  the  Inspector 
shall  give  full  instructions  to  the  family. 

Cases  of  questionable  diagnosis  must  be  seen,  at  once,  in  consultation, 
with  the  Borough  or  Chief  Diagnostician,  and  whenever  required,  a  spinal 
puncture  shall  be  made  and  a  laboratory  report  submitted  by  the  staff  of 
the  Research  Laboratory.  Cases  with  positive  laboratory  findings  will  be 
considered  as  Poliomyelitis,  regardless  of  clinical  signs.  A  full  history 
must  be  recorded  on  a  special  card  (Form  316-V)  for  each  assignment 
covered  by  Inspectors. 

Duties  of  Nurses. — Nurses  shall  visit  every  case  reported,  to  instruct 
the  family  regarding  quarantine,  and  every  other  family  in  the  house: 

a.  That  there  is  a  case  of  this  disease  in  the  house. 

b.  That  the  other  children  of  the  family  in  which  the  disease 
has  occurred  shall  be  quarantined,  and  that,  should  they  fail  to  ob- 
serve quarantine,  that  fact  should  be  immediately  reported  to  the 
Department  of  Health,  when  steps  shall  be  taken  to  enforce  quaran- 
tine by  a  summons  to  Court. 


299 

c.  Regarding  home  cleanliness,  personal  hygiene,  and  danger 
of  infection  by  flies,  and  other  general  measures  which  should  be 
taken  to  prevent  infection. 

d.  To  report  at  once  to  the  Department  any  cases  of  suspicious 
illness  of  children,  or  any  cases  of  Poliomyelitis,  especially  if  there 
is  no  physician  in'  attendance. 

A  current  history  (Form  304-\')  must  be  kept  by  the  nurse  for  every 
case,  giving  dates  of  visits,  action  taken  and  date  and  mode  of  termination. 

Nurses  must  see  the  janitor  or  his  or  her  representative  on  first  visit 
and  repeat  the  instructions  given  by  the  Inspector. 

Patients  remaining  at  home,  and  families  with  quarantined  children, 
shall  be  visited  daily,  or  more  often  if  necessary,  by  a  nurse  or  patrolman 
for  the  purpose  of  ascertaining  whether  or  not  the  Regulations  governing 
the  maintenance  of  quarantine  are  being  complied  with.  After  removal, 
recoverv.  or  death  of  the  patient,  nurses  shall  issue  renovation  notices  and 
make  subsequent  reinspections  until  the  terms  of  such  notices  have  been 
complied  with. 

Duties  of  Sanitary  Police. — Sanitary  police  officers  shall  visit  quaran- 
tined premises  frequently,  daily  if  necessary,  to  enforce  quarantine  of 
patient  and  other  children  in  the  family  and  to  affix  or  replace  placards. 
If  quarantine  Regulations  are  violated,  they  are  authorized  to  serve  a  sum- 
mons upon  the  person  responsible  therefor. 

Duties  of  Ambulance  Surgeons. — All  cases  ordered  removed  to  the 
hospital  must  be  removed  by  the  ambulance  surgeon  without  question,  with 
the  following  exceptions,  in  each  of  which  the  ambulance  surgeon  must  first 
obtain  telephone  authorization  from  the  Resident  Physician  of  his  hospital, 
to  leave  the  case  at  home : 

a.  When  removal  would  endanger  life  of  child  (bulbar  cases). 

b.  When  family  physician  can  show  that  requirements  will  be 
met  at  once  (or  within  12  hours). 

Doubtful  and  mixed  infection  cases  must  be  removed  by  themselves  in 
a  separate  ambulance. 

In  every  case  ambulance  surgeons  must  leave  a  card  with  parents, 
giving  name  and  address  of  hospital  to  which  patient  is  taken.  If  inspector 
has  not  left  admission  slip,  surgeon  must  make  out  same. 

Persons  leaving  Nezv  York  State. — Officers  of  the  U.  S.  Public  Health 
Service,  stationed  at  transportation  terminals,  require  the  above  certificates 
before  they  will  permit  children  under  fifteen  (15)  years  of  age.  resident 
in  New  York  City,  traveling  to  points  outside  of  the  State  of  New  York, 
to  leave  the  City.  The  original  applicant  must  again  sign  the  certificate  in 
the  presence  of  the  Federal  Health  Officer.  Federal  Health  Officers  do  not 
require  certificates  of  any  adults. 

Persons  Going  to  Points  within  Xezc  York  State.— Residents  of  New 
York  Citv,  adults  or  children,  traveling  to  points  within  New  York  State, 


who  present  certificates  of  good  health  from  their  family  physicians,  may 
also  obtain  the  above  certificates  from  the  Department  of  Health.  If  no 
physician's  certificate  of  good  health  is  presented,  applicants  will  be  examined 
by  a  physician  and  their  freedom  from  symptoms  of  Poliomyelitis  certified; 
in  this  case,  all  children  must  be  brought  to  the  proper  office  of  the  Depart- 
ment. 


(Leaflet.) 

(Issued  July  20,  1916.) 

INFANTILE    PARALYSIS. 

(Poliomyelitis.) 


Information  for  the  Public. 

Infantile  Paralysis  (Poliomyelitis)  is  a  catching  disease.  How  it  is 
spread  is  not  yet  definitely  known.  In  most  cases  the  disease  is  probably 
taken  directly  from  a  sick  person,  but  it  may  be  spread  indirectly,  through 
a  third  person  who  has  been  taking  care  of  the  patient,  or  through  children 
who  have  been  living  in  the  same  household. 

The  early  symptoms  are  usually  fever,  weakness,  fretfulness  or  irrita- 
bility, and  vomiting.  There  may  or  may  not  be  acute  pain  at  this  time. 
Later,  there  is  pain  in  the  neck,  back,  arms  or  legs,  with  great  weakness. 
If  paralysis  is  to  occur,  it  usually  appears  from  the  second  to  the  fifth  day 
after  the  sickness  begins.    Many  cases  do  not  go  on  to  paralysis. 

The  germ  of  the  disease  is  present  in  discharges  from  the  nose,  throat 
and  bowels  of  those  ill  with  infantile  paralysis,  even  in  the  cases  that  do  not 
go  on  to  paralysis.  It  may  also  be  present  in  the  nose  and  throat  of  healthy 
children  from  the  same  family.  Do  not  let  your  children  play  with  children 
who  have  just  been  sick  or  who  have  or  recently  have  had  colds,  summer 
complaint,  etc.  For  this  reason  children  from  a  family  in  which  there  is 
a  case  of  infantile  paralysis  are  forbidden  to  leave  their  home.  If  you 
hear  of  their  doing  so,  report  it  at  once  to  the  Department  of  Health. 

Persons  over  16  years  of  age,  from  families  where  there  are  cases  of 
poliomyelitis,  may  continue  at  work  unless  their  business  has  to  do  with 
the  preparation  or  handling  of  food  or  drink  for  sale. 

If  you  hear  of  a  case  in  your  neighborhood  and  the  house  is  not 
placarded,  notify  the  Department  of  Health. 

How  to  Guard  Against  the  Disease. 

In  order  to  prevent  the  occurrence  of  this  disease,  parents  should 
observe  the  following  rules  : 

Keep  your  house  or  apartment  absolutely  clean. 
Go  over  all  woodwork  daily  with  a  damp  cloth. 


301 

Sweep  floors  only  alter  they  have  been  sprinkled  with  sawdust,  old 
tea-leaves,  or  bits  of  newspaper  which  have  been  thoroughly  dampened. 
Never  allow  dry  sweeping. 

Screen  your  windows  against  flies,  and  kill  all  flies  in  the  house. 

Do  not  allow  garbage  to  accumulate,  and  keep  pail  closely  covered. 

Do  not  allow  refuse  of  any  kind  to  remain  in  your  rooms. 

Kill  all  forms  of  vermin,  such  as  bedbugs,  roaches  and  body-lice. 

Pay  special  attention  to  bodily  cleanliness.  Give  the  children  a  bath 
every  day  and  see  that  all  clothing  which  comes  into  contact  with  the  skin 
is  clean. 

Keep  your  children  by  themselves  as  much  as  possible.  Do  not  allow 
them  to  visit  moving  picture  shows  or  other  places  where  children  may 
gather. 

Children  should  not  be  kept  in  the  house ;  they  should  be  out-of-doors 
as  much  as  possible,  but  not  in  active  contact  with  other  children  of  the 
neighborhood.  Do  not  take  them  on  a  street  car,  unless  absolutely  neces- 
sary, or  shopping. 

Do  not  allow  your  children  to  be  kissed. 

It  is  perfectly  safe  to  let  your  children  go  to  the  parks  and  playgrounds 
if  only  two  or  three  of  them  play  together;  they  should  not  play  in  large 
groups,  and  you  should  not  let  them  come  into  contact  with  children  from 
other  parts  of  the  city. 

Remember  that  children  need  fresh  air  in  the  summer  time,  and  outdoor' 
life  is  one  of  the  best  ways  to  avoid  disease. 

If  there  is  a  public  shower  bath  in  a  school  in  your  vicinity,  send  the 
older  children  there  every  day  for  a  showier  bath.  This  is  perfectly  safe 
and  will  help  keep  them  in  good  health. 

Give  your  children  plain,  wholesome  food,  including  plenty  of  milk  and 
vegetables. 

Keep  the  milk  clean,  covered  and  cold. 

Do  not  allow  the  milk  or  any  other  food  to  be  exposed  where  flies  may 
alight  upon  it. 

Wash  well  all  food  that  is  to  be  eaten  raw. 

In  Case  of  Sickness. 

Remember  that  during  the  hot  weather  children  are  apt  to  have  stomach 
and  bowel  troubles.  If  your  child  is  taken  sick  with  loose  movements  of 
the  bowels,  or  with  vomiting,  do  not  at  once  fear  that  it  must  be  infantile 
paralysis ;  it  may  be  simply  digestive  disturbance.  Give  the  child  a  table- 
spoonful  of  castor  oil  and  plenty  of  cool  water  to  drink,  and  send  for  the 
doctor  at  once. 

If  you  cannot  afford  a  doctor's  services,  telephone  the  Department  of 
Health  and  one  will  be  sent  free  of  charge. 


302 

If  a  doctor  or  nurse  from  the  Department  of  Health  visits  your  home, 
give  them  all  the  information  you  can.  They  are  sent  to  show  you  how  to 
keep  your  children  well. 

Do  not  give  your  children  patent  medicines  or  buy  charms  of  any  kind 
to  ward  off  the  disease.  The  best  preventive  is  cleanliness  and  strict  observ- 
ance of  the  rules  that  have  been  given. 

Although  there  is  no  specific  cure  for  the  disease,  much  can  be  done  to 
reduce  the  amount  of  crippling  caused  by  the  paralysis.  It  is  important  to 
remember  that  this  requires  the  services  of  a  trained  physician  and  the  care 
of  a  competent  nurse.  Unless  you  can  give  these  to  your  child,  send  word 
at  once  to  the  Department  of  Health,  so  that  the  patient  may  receive  proper 
care  in  a  well-equipped  hospital.  Of  the  children  cared  for  in  hospitals, 
only  one-quarter  as  many  died  as  of  those  treated  at  home.  Give  your  child 
a  fair  chance  and  let  the  hospital  doctors  care  for  it. 

What  the  Health  Department  Will  Do. 

If  a  case  of  infantile  paralysis  occurs  in  your  home,  your  doctor  must 
at  once  notify  the  Department  of  Health.  An  inspector  will  be  sent  to 
investigate.  He  will  paste  a  sign  on  the  door  of  your  house  and  apartment 
warning  all  people- not  to  enter.  This  sign  must  not  be  removed  except  by 
some  one  sent  by  the  Department  of  Health.  The  inspector  and  nurse  will 
tell  you  just  what  to  do  to  protect  yourself  and  the  others  in  the  family. 

Should  you  want  any  further  information,  write  or  telephone  to  the 

Bureau  of  Preventable  Diseases 

Department  of  Health,  City  of  New  York 

139  Centre  Street,  New  York. 


(Leaflet.) 

(Issued  July  20,  1916.) 

POLIOMYELITIS. 

Information  for  Physicians. 

Early  Diagnosis. 

The  attention  of  physicians  is  called  to  the  necessity  of  an  early  diag- 
nosis of  all  cases  of  poliomyelitis.  Early  recognition  and  strict  quarantine 
are  the  chief  weapons  against  the  disease. 

Reporting  of  Cases. 

All  suspicious  cases  must  be  at  on<ce  reported  to  the  Department  of 
Health  by  Telephone,  to  be  followed  within  twenty-four  hours  by  a  written 
report.  The  ability  of  the  Department  of  Health  to  limit  the  spread  of  the 
infection  depends  upon  the  immediate  reporting  of  every  suspicious  case. 


303 

Age  of  Persons  Affected. 

It  should  be  remembered  that  this  disease  may  occur  at  all  ages, 
although  the  great  majority  of  the  cases  are  found  in  children  between  the 
ages  of  one  and  five  years. 

Type  of  Disease. 

Peabody,  Draper  and  Dochez,  of  the  Rockefeller  Institute,  give  the 
following  classification  of  the  disease : 

1.  The  non-paralytic  or  so-called  abortive  cases. 

2.  The  cerebral  group,  with  spastic  paralysis. 

3.  The  bulbo-spinal  group. 

Methods  of  Infection. 

The  experiments  of  Landsteiner  and  Popper  in  Germany;  Kling,  Pet- 
terson  and  Wernstedt  in  Sweden,  and  of  Flexner  and  Noguchi  in  this 
country,  have  proved  that  the  disease  is  transmitted  by  the  secretions  of 
the  nose  and  mouth,  and  the  bowel  discharges  of  an  infected  person.  The 
infection  is  transmitted  through  the  mouth,  tonsils  and  nasal  mucous  mem- 
brane. 

Contacts  and  Carriers. 

It  must  be  remembered  that  while  the  transmission  of  the  disease  from 
a  patient  to  other  members  of  the  same  family  is  not  usual,  transmission  of 
the  virus  is  common.  Experience  warrants  the  assumption  that  in  addition 
to  direct  contact,  the  disease  is  spread  by  carriers,  usually  children,  who 
are  themselves  immune  but  who  harbor  the  infective  material  in  their  nasal 
or  mouth  secretions. 

Symptoms. 

Early  symptoms  to  be  regarded  as  suspicious  are:  Fever,  vomiting, 
slight  diarrhoea,  listlessness,  unusual  fretfulness  and  drowsiness.  Later, 
and  more  characteristic  symptoms,  are:  The  appearance  of  weakness  in 
any  extremity,  skin  and  muscular  sensitiveness,  spinal  pain,  especially  on 
flexion,  apparent  or  real  rigidity  of  the  neck  muscles,  Kernig's  and  Mac- 
Ewen's  signs. 

Course  and  Duration  of  Disease. 

Paralysis  appears  usually  before  the  sixth  day  of  the  illness;  it  may 
occur  as  early  as  the  first  day.  Other  symptoms,  except  spinal  and  muscular 
pain  and  rigidity  and  skin  sensitiveness,  rarely  persist. 

Non-Paralytic  or  So-C ailed  Abortive  Cases. 
Non-paralytic  or  so-called  abortive  cases  are  very  frequent.     In  some 
epidemics  they  constitute  from  25  to  50  per  cent,  of  the  diagnosed  cases. 
The  children  have  the  early  symptoms  just  mentioned,  perhaps  also  the 


304 

muscular  tenderness  and  spinal  pain.  If  carefully  observed  it  may  be 
noticed  that  they  develop  a  paralysis  of  one  or  more  groups  of  muscles,  but 
that  instead  of  the  paralysis  continuing  it  all  disappears  within  a  few  hours. 
It  is  obvious  that  the  recognition  of  such  cases  is  of  extreme  importance  in 
controlling  the  spread  of  the  disease.  The  diagnosis  of  such  cases  is  greatly 
facilitated  by  an  examination  of  cerebrospinal  fluid  obtained  through  lumbar 
puncture. 

General  Care  of  Patient. 

Complete  rest  is  of  the  utmost  importance  for  either  paralyzed  or  weak 
muscles  for  the  first  five  or  six  weeks.  Every  effort  must  be  taken  to  make 
this  rest  complete.  The  limb  must  not  be  allowed  to  dray  on  a  paralyzed 
muscle.  It  should  be  supported  by  pillows  or  pads  or  bandages.  There 
seems  to  be  a  greater  tendency  to  atrophy  if  casts  are  used.  A  dropped 
foot  may  be  supported  by  a  sandbag  or  pillow ;  small  rolls  placed  under  the 
knee  often  hold  the  leg  in  a  more  comfortable  position.  The  weight  of  the 
clothing  should  be  kept  ofif  the  legs  by  hoops  or  other  device  If  the  head 
is  somewhat  retracted  and  the  patient  desires  to  lie  on  his  back,  he  may 
sometimes  be  made  more  comfortable  by  a  small  pillow  placed  under  the 
shoulders,  allowing  the  head  to  fall  back.  The  value  of  electricity  for 
treatment  in  the  first  six  weeks  is  very  doubtful.  In  many  instances  it  may 
do  harm.  Massage  or  passive  movements  should  not  be  begim  for  at  least 
five  or  six  weeks  and  then  should  be  used  with  great  care.  In  cases  that 
show  a  tendency  to  clear  up  rapidly,  the  child  should  be  kept  in  bed  for 
some  time  after  the  ability  to  use  the  muscles  returns.  It  should  never  be 
encouraged  to  try  to  stand  or  to  use  the  muscles  otherwise  until  a  consider- 
able time  has  passed. 

Period  of  Incubation  and  Duration  of  Disease. 

The  incubation  period  has  been  officially  set  at  two  weeks.  Non- 
immune, infected  persons  usually  manifest  symptoms  of  the  disease  in  from 
five  to  ten  days  after  exposure.  The  average  period  of  incubation  is  seven 
days.  The  early  symptoms,  noted  above,  usually  last  from  one  to  seven 
days.  Quarantine  of  the  patient  will  be  maintained  for  a  period  of  at  least 
eight  weeks. 

Prevention  of  Spread  of  Infection. 

1.  The  children  from  an  infected  family  will  be  confined  to  the  house, 
(See  "  Quarantine.") 

2.  During  the  continuance  of  an  epidemic  of  poliomyelitis  children 
should  not  be  allowed  to  congregate  in  public  places. 

3.  Fresh  air  outings  or  vacation  camps  are  allowed,  if  kept  under 
competent  medical  supervision,  with  an  adequate  physical  examination  of 
each  child  before,  enrollment  and  the  exclusion  of  any  child  from  an 
infected  family. 


305 

4.  Absolute  cleanliness  of  all  homes  is  essential ;  such  cleanliness 
should  include : 

(a)  Screens  in  all  windows. 

(b)  Flies  kept  out  of  all  rooms. 

(c)  Thorough  cleanliness  of  all  floors,  woodwork,  bedding  and 
clothing. 

(d)  Avoidance  of  dust  (all  sweepings  should  be  done  after  the 
floors  have  been  sprinkled  with  sawdust,  bits  of  newspaper  or  tea 
leaves,  all  thoroughly  moistened). 

(e)  Garbage  cans  kept  closely  covered  and  washed  out  in  hot 
soapsuds  after  they  have  been  emptied. 

(/)  No  refuse,  either  of  food  or  other  waste,  allowed  to  accumu- 
late. 

5.  Personal  habits  of  cleanliness  are  essential ;  the  hands  should  be 
washed  before  each  meal,  after  each  visit  to  the  toilet,  and  before  going  to 
bed.  Children  should  be  warned  about  putting  the  fingers  into  the  mouth 
or  nostrils. 

6.  When  sneezing  or  coughing,  a  handkerchief  should  be  held  over 
the  mouth.  Kissing  of  children  is  also  a  dangerous  practice  and  should  be 
avoided. 

Procedure  to  Be  Followed  in  Each  Case. 

Isolation  of  Patient. 

1.  Complete  isolation  of  the  patient  must  be  maintained  until  ter- 
minated by  order  of  the  Department  of  Health. 

2.  A  separate  room  must  be  provided  for  the  patient.  No  one  must 
be  allowed  in  this  room  except  the  attending  physician,  the  nurse  and  the 
representative  of  the  Department  of  Health. 

Care  of  Patient's  Room  and  Surroundings. 

3.  (A)  All  rugs,  carpets,  draperies  and  unnecessary  furniture  must 

be  removed  before  the  patient  is  placed  in  the  room. 

(B)  All  windows  must  be  screened. 

(C)  The  sick  room  must  be  kept  well  aired  at  all  times. 

(D)  The  woodwork  must  be  wiped  daily  with  damp  cloths.    Under  no 

circumstances  must  the  floor  be  swept  when  it  is  dry.  It 
should  be  sprinkled  with  sawdust,  bits  of  newspaper  or  tea 
leaves,  all  thoroughly  moistened,  and  then  carefully  swept  so 
that  no  dust  may  arise. 

(E)  Toys  and  books  used  by  the  patient  must  be  destroyed  by  burning 

after  recovery  or  death. 

(F)  Household  pets  must  not  be  allowed  in  the  room. 

Care  of  Bedding. 

4.  All  cloths,  bed  linen  and  personal  clothing  which  have  come  into 
contact  in  any  way  with  the  patient  must  immediately  be  immersed  in  a 


306 

five  per  cent,  solution  of  carbolic  acid  and  allowed  to  soak  for  three  hours. 
They  may  then  be  removed  from  the  room  and  must  be  boiled  in  water  or 
soapsuds  for  fifteen  minutes. 

Care  of  Discharges  from  Body. 

5.  A  sufificient  supply  of  gauze  or  clean  linen  or  cotton  cloth  must  be 
provided  and  all  discharges  from  the  nose  and  mouth  of  the  patient  received 
on  these  cloths.    After  use,  they  must  be  immediately  burned  or  boiled. 

Bowel  discharges  and  urine  must  be  covered  at  once  with  chloride  of 
lime  and  then  disposed  of  by  emptying  into  a  water  closet. 

Care  of  Utensils  Used  by  Patient. 

6.  Plates,  cups,  glasses,  knives,  forks,  spoons  and  other  utensils  used 
by  the  patient  must  be  kept  for  his  exclusive  use  and  under  no  circumstances 
removed  from  the  room  or  mixed  with  similar  utensils  used  by  other.  They 
must  be  washed  in  the  room  in  hot  soapsuds  and  then  rinsed  in  boiling 
water.  After  use,  the  soapsuds  and  water  must  be  thrown  into  the  water 
closet. 

Nurse. 

7.  A  trained  nurse  or  competent  attendant  must  be  in  sole  attendance 
upon  the  patient.  She  must  not  be  allowed  to  mingle  with  the  rest  of  the 
family  but  must  be  isolated  with  the  patient.  The  hands  of  the  nurse  must 
be  carefully  washed  in  hot  soapsuds  after  each  contact  with  the  patient  and 
before  eating. 

Termination  of  Case. 

8.  After  the  case  has  been  ordered  terminated  by  the  Department  of 
Health,  the  following  procedure  must  be  followed : 

(a)  The  entire  body  of  the  patient  must  be  bathed  and  their 
hair  washed  with  hot  soapsuds.  The  patient  should  then  be  dressed 
in  clean  clothes  (which  have  not  been  in  the  sick  room  during  the 
illness)  and  removed  from  the  room. 

(b)  The  nurse  should  also  take  a  bath,  wash  her  hair,  and  put 
on  clean  clothes  before  mingling  with  the  family  or  other  people. 

Action  Taken  by  the  Department  of  Health  in  Each  Case. 

Placarding. 

Every  house  will  be  placarded  without  exception.  In  private  houses 
one  placard  is  placed  on  the  street  front  (outside  of  house),  and  one  placard 
is  placed  on  the  door  entering  the  room,  patient  is  in.  In  tenements  three 
placards  are  affixed,  one  on  street  door,  one  in  entrance  hall  and  one  on 
door  of  apartment.     All  placards  are  dated. 

Quarantine. 
In  all   familie's  where  a  case  of  poliomyelitis  has  occurred  all  other 
children  under  sixteen  years  except  those  who  have  had  the  disease  are  to 


307 

be  quarantined  in  the  home  until  two  weeks  after  the  termination  of  the 
case  by  death,  removal  or  recovery. 

The  patient,  whether  at  home  or  in  hospital,  must  be  quarantined  for 
eight  weeks  from  onset  of  disease. 

Children  under  sixteen  (16)  years  of  age  who  have  been,  but  no  longer 
are,  exposed  to  infection  will  be  quarantined  for  fourteen  days. 

Removal  to  Hospital. 

No  case  is  to  be  left  at  home  unless  the  following  conditions  are  com- 
plied with : 

(a)  There  must  be  a  private  physician  in  attendance  regularly. 

(b)  Person  attending  patient  must  obey  quarantine  rules;  must 
not  do  any  housework,  marketing  or  leave  premises. 

(c)  Patient  and  attendant  must  have  separate  room. 

(d)  All  windows  of  rooms  used  by  patient  must  be  screened, 

(e)  The  family  must  have  a  separate  toilet  for  its  exclusive  use. 
(/)   Quarantine  regulations  must  be  strictly  observed  by  patient 

and  other  children. 

Deaths. 

In  case  of  death  prompt  burial  is  required,  the  cofifin  must  be  sealed  as 
in  deaths  from  other  contagious  diseases,  and  the  funeral  must  be  strictly 
private.     Church  funerals  are  prohibited. 

Spinal  Puncture. 

Physicians  desiring  the  services  of  a  consultant  to  perform  lumbar 
puncture  and  report  on  the  examination  of  spinal  fluid  should  telephone  to 
the  Bureau  of  Laboratories,  Department  of  Health,  1600  Stuyvesant. 

Physicians  desiring  further  information  should  write  to  the 

Bureau  of  Preventable  Diseases 

Department  of  Health,  City  of  New  York 

139  Centre  Street,  New  York  City 


(  Placard.  ) 
(Issued  July  15,  1916.) 
INFANTILE  PARALYSIS 
(Poliomyelitis). 

Infantile  Paralysis  is  very  prevalent  in  this  part  of  the  city.  On  some 
streets  many  children  are  ill. 

Keep  your  children  off  the  streets  as  much  as  possible  and  be  sure  to 
keep  them  out  of  the  houses  on  which  the  Board  of  Health  has  put  a  sign. 

This  is  a  disease  which  babies  and  young  children  gtt ;  many  of  them 
die ;  and  many  who  do  not,  become  paralyzed  for  life. 


308 

Don't  let  your  children  go  to  parties  or  picnics  or  outings. 
Don't  let  them  play  with  any  children  who  have  sickness  at  home. 
The  daily  papers  will  tell  you  in  what  houses  the  disease  is. 
If  your  child  is  sick,  send  for  your  doctor  at  once,  or  send  word  to  the 
Board  of  Health. 

Manhattan,  Centre  and  Walker  Streets.    Tel.  6280  Franklin. 
The  Bronx,  Third  Avenue  and  St.  Paul's  Place.     Tel.  1975  Tremont. 
Brooklyn,  Flatbush  Avenue  and  Willoughby  Street.    Tel.  4720  Main. 
Queens,  374  Fulton  Street,  Jamaica.    Tel.  1200  Jamaica. 
Richmond,  514-516  Bay  Street,  Stapleton.    Tel.  440  Tompkinsville. 


(Leaflet.) 
(Issued  August  10,  1916.) 

WHAT  EVERY  MOTHER  SHOULD  KNOW 

ABOUT 

INFANTILE  PARALYSIS 


Infantile  Paralysis  (also  called  Poliomyelitis)  is  a  catching  disease 
caused  by  a  tiny  germ.  The  disease  occurs  mostly  in  young  children, 
but  now  and  then  attacks  older  persons. 

It  is  not  difficult  to  recognize  typical  cases  of  the  disease.  Here  is  a 
common  picture:  A  child  previously  perfectly  well  complains  of  a  little 
stomach  trouble  or  diarrhoea.  It  is  feverish,  restless  and  irritable.  In 
the  morning  the  mother  finds  that  the  child  cannot  stand  or  perhaps 
that  it  cannot  move  its  arms. 

Parents  should  be  on  the  lookout  for  all  cases  of  illness  in  their 
children.  No  matter  how  mild  it  is  advisable  to  seek  a  doctor's  advice. 
Don't  be  misled  by  patent  medicine  advertisements.  The  country  is 
already  being  flooded  by  announcements  of  quacks  who  want  to  sell 
their  stuff.  None  of  their  medicines  are  any  good.  Camphor  will  not 
do  any  good.     See  a  doctor ! 

The  germ  of  the  disease  is  present  in  discharges  from  the  nose, 
throat  and  bowels  of  those  ill  with  infantile  paralysis,  even  in  the  cases 
that  do  not  go  on  to  paralysis.  It  may  also  be  present  in  the  nose  and 
throat  of  healthy  children  from  the  same  family.  Do  not  let  your 
children  play  with  children  who  have  just  been  sick  or  who  have  or 
recently  have  had  colds,  summer  complaint,  etc.  For  this  reason  children 
from  a  family  in  which  there  is  a  case  of  infantile  paralysis  are  for- 
bidden to  leave  their  home.  If  you  hear  of  their  doing  so,  report  it  at 
once  to  the  Department  of  Health. 

Much  can  be  done  to  reduce  the  amount  of  crippling  caused  by  the 
paralysis.  Remember  that  this  requires  the  services  of  a  trained 
physician  and  the  care  of  a  competent  nurse.  Unless  you  can  give  these 
to  your  child,  send  word  at  once  to  the  Department  of  Health,  so  that 
the  patient  may  receive  proper  care  in  a  well-equipped  hospital.  Of 
the  children  cared  for  in  hospitals,  only  one-quarter  as  many  die  as  of 
those  treated  at  home.  Give  your  child  a  fair  chance  and  let  the  hospital 
doctors  care  for  it. 


309 


What  the  Health  Department  Will  Do. 

If  a  case  of  infantile  paralysis  occurs  in  your  home,  j'our  doctor  must 
at  once  notify  the  Department  of  Health.  An  inspector  will  be  sent  to 
investigate.  He  will  paste  a  sign  on  the  door  of  your  house  and  apart- 
ment warning  all  people  not  to  enter.  This  sign  must  not  be  removed 
except  by  some  one  sent  by  the  Department  of  Health.  The  inspector 
and  nurse  will  tell  you  just  what  to  do  to  protect  yourself  and  the 
others  in  the  family. 

Should   you   want    any    further    information    write    or    telephone   to    the 

DEPARTMENT  OF  HEALTH 
139   CENTRE   STREET,    NEW    YORK 

Telephone  6280  Franklin 


[The  other  side  of  this  leaflet  bore  the  following:] 

INFANTILE  PARALYSIS  IS  DANGEROUS! 


CLEAN  UP  AND  KEEP  CLEAN! 

KEEP   your   children   clean.     Bathe   them   frequently.     See   that  they 
keep  their  hands  particularly  clean.     Be  sure  that  each  child  has  its 
own  clean  handkerchief. 
Keep  your  house  unusually  clean.     Don't  allow  a  fly  in  it.     Keep  your 
garbage  bucket  clean  and  tightly  covered. 

Have  a  general  house-cleaning.  Throw  away  all  useless  knick-knacks 
and  rubbish.  Use  soap  and  water  generously,  and  let  nature  kill  the 
germs  with  sunshine  and  fresh  air. 


310 

Keep  your  children  away  from  places  where  the  disease  exists. 

Don't  let  your  children  play  with  groups  of  children.  Don't  let  them 
attend  parties  and  festivals.     Don't  take  them  to  movies. 

Give  them  all  the  fresh  air  you  can,  but  not  on  crowded  streets, 
trolley-cars  or  boats. 

If  you  have  a  garden,  keep  the  children  there.  Use  the  roof  if  you 
live  in  a  house  where  there  are  no  cases  of  the  disease. 

Wash  out  your  child's  mouth  and  nose  frequently  with  Boracic  Acid 
solution  or  plain  boiled  water  with  a  little  salt  in  it. 

Give  your  child  cold  boiled  water  (that  has  been  kept  covered) 
to  drink. 

Be  careful  of  diet.     Give  light,  easily  digested  food. 

Let  your  child  have  plenty  of  rest.     Put  it  to  bed  early  in  the  evening. 

Keep  your  child's  bowels  in  good  order.  If  you  notice  symptoms 
of  fever,  vomiting  or  tiredness,  give  a  dose  of  Castor  Oil.  Put  the  child 
to  bed  in  a  room  alone  and  CALL  A  DOCTOR.  Keep  all  other  children 
away  until  your  child  is  well. 

COVER  ALL  FOOD  THAT  IS  TO  BE  EATEN. 


(Press  Bulletin) 


From  the  Department  of  Health 
Gty  of  N«w  York 


OFFICIAL 


To  the  Editor:      » 

A  very  large  part  of  the  work  of  the  Department  of  Health  depends  for  its  success  on  the  co-operation  of  an 
enlightened  public,  and  this,  in  turn,  depends  almost  entirely  on  the  amount  of  space  accorded  to  health  articles  by 
the  newspapers. 

If,  when  this  reaches  your  office,  your  men  are  out  on  stories  and  you  desire  further  information,  we  shalf 
be  glad  to  answer  your  inquiries  o*er  the  telephone.     Please  ask  for 

The  Bureau  of  public  health  education 

DEPARTMENT  OF  HEALTH 
m'f&vKUH  139  Centre  Street,  New  York 


PRESS    BULLETIN._^j7<r... 


Issued  (Date)  -^cfil,  %y 


RELEASE    ,^»,^„,^^V^. 


New  Cases  of  Poliomyelitis — September  22,  1916. 


New    Dropped  as 
Cases.     No  Cases. 


Total 
Cases. 


Deaths. 


Total 
Deaths. 


Manhattan 
Bronx  . . . 
Brooklyn  . 
Queens  . . 
Richmond 


Total. 


9 

2,429 

3 

622 

3 

587 

2 

137 

5 

4,470 

5 

1,105 

3 

1,093 

1 

306 

282 

56 

20 


8,861 


11 


2,226 


Total  Cases  in  Hospital. 
Department  Hospitals  . . 
Other  City  Hospitals    . . . 

Private  Hospitals  

Swinburne  Island  

Vacancies    


2,823 

1,982 

449 

352 

40 

460 


311 

Cases  Terminated. 


Cases  Cases 

Removed,     at  Home. 


Hospitals. 


Total 
to  Date. 


Manhattan    . . . . 

Bronx  

Brooklj^n   

Queens    

Richmond    

Total . 


3 

32 

28 

979 

4 

4 

2 

87 

4 

7 

19 

1,412 

2 

4 

7 

187 

143 

15 


47 


56 


Cert. 

Issued. 


Cert. 
Issued, 
to  Date. 


Cert. 
Refused. 


Cert. 
Refused 
to  Date. 


Manhattan    

Bronx    

Brooklyn    

Queens   

Richmojnd    

Total. 


362 

48,144 

191 

67 

18,771 

56 

343 

59,490 

217 

68 

13,988 

5 

18 

2.107 

3 

858 


142,500 


(Here  followed  an  alphabetical  list  of  the  cases.) 


474 


(Circular  Letter.) 

{Sent  to  all  physicians  in  the  city.) 

Office  of  the  Commissioner. 

July  19,  1916. 
Dear  Doctor : 

The  present  epidemic  of  poliomyelitis  affords  an  unparalleled  oppor- 
tunity for  clinical  study  and  observation.  The  Department  of  Health, 
through  the  co-operation  of  various  hospitals  which  are  treating  a  large 
number  of  cases  of  polimyelitis,  has  arranged  a  series  of  clinical  lectures 
open  only  to  physicians,  to  be  conducted  by  men  who  have  had  an  unusual 
opportunity  to  study  this  disease.  You  are  cordially  invited  to  attend 
any  and  all  of  these  clinics,  and  the  Department  hopes  that  you  will  take 
advantage  of  this  exceptional  opportunity.     These  clinics  are  to  be  con- 


312 

ducted  during  the  week  commencing  Monday,  July  24,  at  the   following 
hospitals : 

Willard  Parker  Hospital — 

Dr.  Philip  Van  Ingen  and  Associates. 

4-5  P.  M. 

Monday,  Tuesday,  Wednesday,  Thursday  and  Friday. 

Kingston  Avenue  Hospital — 

Dr.  Louis  Ager  and  Associates. 

4-5  P.  M. 

Monday,  Tuesday,  Wednesday,  Thursday  and  Friday. 

Mt.  Sinai  Hospital — 

Dr.  Herman  Schwarz. 

4-5  P.  M. 

Monday,  Tuesday,  Wednesday,  Thursday  and  Friday. 

Bellevue  Hospital — 

Dr.  J.  S.  Ferguson  (Isolation  Pavilion,  Ward  32). 

4-5  P.  M. 

Tuesday,  Thursday  and  Saturday. 

Babies'  Hospital — 

Dr.  Charles  Gilmo're  Kerley. 

4:30-5:30  P.  M. 

Tuesday  and  Thursday.  , 

Swinburne  Island — 

Dr.  Frank  Clark  (Quarantine  Station). 

4-5  P.  M. 

Thursday  and  Friday. 

Very  truly  yours. 

Haven  Emerson,  M.D., 

Commissioner. 


313 


314 


315 


CL, 


'•J 


cu 


Q^ 


316 


317 


c 


u 


318 


One  of  the  Little  Patients.     Left  Leg  Paralyzed. 


319 


320 


(In 


ffi 


o, 


Ph 


u 


321 


o 


322 


323 


> 


'J 


324 


a 

o 

K 


2 

ID 

Pi 


...  :...»^.^.-..-,^^.„,,.....:laaaia£.;-^,.. . . , .  ....^Jiiii 


325 

Maps. 

In  the  following  pages  are  shown  reproductions  of  the  Brooklyn  pin 
maps  (the  originals  approximately  5  by  7  feet),  on  which  all  the  cases 
were  shown  by  means  of  pins.  In  the  maps  here  given  the  cases  have  been 
plotted  according  to  the  date  of  onset,  a  method  which  furnishes  an  accurate 
picture  of  the  course  of  the  epidemic. 


-.-  .•%<■ 


'■/— 


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s^    JRROOKLYN 


Onsets  in  Month  of  May,  1916.  lS663-Beals-N.  Y. 


It;  1.1    ' '     ,  .         '» 

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326 


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.    ^     BROOKLYN 


Onsets  in  First  10  Days  of  June,  1916.  1S665— Beals— N.  Y. 


2,21 


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Onsets  in  Week  Ending  June  24,  1916. 


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329 


I.      O      h'     E      R 


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Onsets  in  "Week  Endins  Tulv  1,  1916. 


330 


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Onsets  in  Week  Ending  July  8,   1916. 


331 


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Onsets  in  Week  Ending  July  15,  1916. 


332 


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Onsets  in  Week  Ending  July  22,  1916. 


333 


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Onsets  in  Week  Ending  July  29,  1916.  18698-Beals-X.  Y. 


334 


K'..      ..<•',     \,., 


h     O     W     E     li 


V 


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*     gROOKLYN 


Onsets  in  Week  Ending  August  5,  1916.  18701— Beals—N.  Y. 


335 


,    ''     '      f      i 


I    o    w    /:    w 


ROOKLYN 


,i       T 


Onsets  in  Week  Ending  August  12,  1916. 


18702— Beals—N.  Y. 


336 


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Onsets  in  Week  Ending  August  19,  1916.  18711— Eeals—N.  T. 


337 


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18712— Seals— N.  Y, 


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339 


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Onsets  in  Week  Ending  September  9,  1916. 


1871-1 — Beals— X.  Y. 


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Onsets  in  Week  Ending  September  16,  1916.  18715— Beals—N.  Y. 


-lilt.  * ..  j«^»  «   .  kt»  •$  rf       *     •       »       *  •  %:*'>• 


Distribution  of  Brooklyn  Cases  in  1916  Epidemic. 


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I    jf  Cases  in  1916  Epidemic  in  Manhattan, 


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Distribution  of  Cases  in  191G  Hp 


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Distribution  of  Cases  in   1916  Epidemic  in  Qui 


• 


iiiiiiiHUiiMiili 


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^:^ 


T 


<      I 


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nistribiitiun  of  Ca 


191f)  Kijidcmic  in  The  Bn 


STANDARD  MAP  OF 


Table  I — Continued. 


1%  4%  of  ( 


lallj- in  one  coumy  (Idaho). 


contagion^t^Bmitted^hrough"  Visits  Jf         four  ras. 
srxtcen^nstances'tworaBesinsk'mc'fami'lir.     74%  undt 


Frost— Hyg.  Lab.  I 


Table  I — Continued. 


7r"r  m^^-i^      The   Slate   Med.    Inst,   of   S^ 
i  of  population  Epidemic  Infantile  Paralysis 


nily. .  -     75  %  chiJdren;  Z5%  adults 

Mostly  younE  children;   5%  adult- 


Sporadic  cases  in   England   since 


nily,  (only  13  of  school  J 


arlty  Tor  reports  o(  the  1910  cpiJen 


Table  11.— POLIOMYELITIS  IN  NEW  YORK  CITY  AND  STATE. 


t320  t20% 


361 

Table  III. 
Poliomyelitis — Cases  and  Deaths  by  Date  of.  Report. 


Manhattan. 


Xo 

1 

Xo 


Bronx. 


Cases 
Cases 


Brooklyn. 


Queens. 


45 
18 
20 
77 
80 
90 
60 
74 
66 
77 
151 
131 
76 
122 
87 
65 
65 
83 
82 
81 
36 
82 
58 


Richmond. 


The  City. 


By  Days. 


By  Weeks 


61 

32 

41 

86 

103 

113 

87 

95 

88 

112 

192 

163 

118 

162 

144 

96 

105 

121 

140 

117 

81 

135 

115 


7 

9 

10 


12 
18 
14 
24 
9 
26 
19 
15 
19 
14 
32 
17 
24 
31 
27 
17 
14 
26 
30 
31 
32 
39 
23 


189 


362 
Table  III — Continued. 


Manhattan. 

Bronx. 

Brooklyn. 

Queens. 

Richmond. 

The  City. 

Q 

cd 
O 

Q 

U 

X. 

a 

IV 

Q 

Q 

U 

a 

a 

By  Days. 

By  Weeks. 

U 

si 
Q 

U 

p 

July,  CoiUinued. 
24 

18 
42 

6 
9 

6 
12 

1 
3 

53 
75 

19 

23 

11 

16 

4 
2 

1 

5 

1 
1 

89 
150 

31 
38 

25 

26 '.  . 

42 
31 

12 

7 

5 
6 

4 
6 

83 
90 

9 
13 

25 
18 

7 
4 

7 
6 

3 

1 

162 
151 

35 
31 

27 

28 

39 

9 

5 

2 

72 

15 

11 

7 

7 

2 

134 

35 

29. 

46 

10 

13 

5 

66 

24 

29 

5 

7 

161 

44 

962 

237 

30 

40 

2 

7 

76 

9 

15 

2 

7 

145 

13 

31 

44 

9 

8 

1 

59 

20 

21 

5 

132 

35 

August: 

1 

42 

12 

8 

83 

33 

17 

10 

9 

159 

55 

2 

46 

17 

8 

88 

16 

20 

8 

4 

166 

41 

3 

76 

11 

8 

2 

92 

21 

33 

8 

8 

217 

43 

4 

52 

10 

9 

1 

84 

32 

28 

2 

3 

176 

45 

5 

51 

7 

7 

2 

83 

22 

27 

9 

5 

173 

41 

1, 

67 

273 

6 

45 

12 

19 

3 

93 

9 

34 

7 

1 

2 

192 

33 

7 

38 

9 

5 

4 

79 

24 

19 

7 

4 

145 

44 

8 

54 
47 

15 
14 

9 

15 

1 
7 

89 
89 

29 
21 

31 
31 

8 
15 

i 

1 

183 
183 

52 
57 

9 

10 

44 

9 

14 

3 

84 

20 

30 

6 

3 

175 

38 

11 

50 

7 

10 

6 

73 

10 

28 

7 

4 

165 

31 

12 

56 

15 

17 

4 

61 

19 

30 

1 

3 

167 

42 

1.; 

,10 

297 

13 

49 

10 

21 

2 

54 

8 

16 

2 

1 

141 

22 

14 

43 

14 

8 

3 

31 

12 

13 

2 

95 

31 

15 

51 

13 

13 

5 

74 

14 

30 

6 

5 

173 

39 

16 

44 
39 

8 
10 

11 
10 

/ 
3 

46 
40 

14 
10 

28 
32 

5 
9 

4 

133 
121 

44 
32 

17 

18 

44 

17 

8 

48 

6 

20 

7 

5 

2 

125 

32 

19 

52 

12 

12 

2 

45 

15 

25 

6 

134 

36 

ni 

236 

20 

37 

9 

15 

2 

40 

6 

14 

3 

2 

108 

20 

21 

32 

17 

9 

6 

29 

8 

21 

2 

1 

92 

33 

22 

48 

19 

9 

4 

42 

11 

16 

4 

3 

118 

39 

23 

52 

12 

10 

6 

43 

15 

23 

9 

3 

131 

42 

24 

59 
43 

12 
14 

6 

14 

i 

31 
24 

14 

7 

10 
11 

4 

3 

2 

109 
94 

31 
22 

25 

26 

36 

9 

13 

13 

27 

8 

15 

3 

92 

25 

i26 

233 

27 

36 

5 

10 

4 

27 

8 

9 

4 

83 

21 

28 

20 

11 

/ 

3 

7 

10 

8 

1 

43 

25 

29 

30 

10 

6 

2 

35 

14 

12 

4 

2 

83 

32 

30 

37 

7 

11 

3 

27 

5 

13 

7 

89 

22 

31. 

26 

10 

3 

4 

25 

6 

6 

1 

60 

21 

September: 

1 

34 

27 

8 

7 

7 
9 

1 

1 

20 
13 

5 
10 

5 
11 

1 
1 

2 

1 

2 

68 
61 

17 
19 

487 

2 

157 

3 

23 

11 

9 

13 

4 

5 

5 

1 

51 

20 

4 

22 
15 
26 
30 
23 
24 
20 
8 
19 

4 
9 
9 
7 
8 
3 
8 
6 

/ 
8 
10 
14 
6 
8 
3 
4 
5 

2 
4 
3 

4 

1 

i 
i 

9 
12 
10 
10 
11 
14 
12 
7 
8 

8 
7 
8 
13 
3 
3 
4 
2 
7 

2 
6 

5 
7 
7 
9 
9 
1 
5 

2 

1 
2 
3 

2 
3 

1 
1 

2 
2 

i 

1 
1 

40 

43 
53 
61 
48 
55 
44 
20 
38 

16 
21 
22 
28 
15 
10 
14 
9 
18 

551 

5 

6 

7.  .  .  , 

8 

9  . 

132 

10 

11 

12 

13 

9 

6 

8 

1 

8 

2 

5 

31 

9 

14. . . . 

19 
24 
13 
12 

5 
12 

8 
10 

9 
13 

3 

6 

5 
lyO 
13 
12 

9 

9 
6 

4 
7 
2 
4 
3 
3 
3 
2 
1 
3 
7 
3 
4 
3 
1 

6 

8 
8 
1 
2 
10 
6 
4 
3 
2 
2 
3 
9 
4 
4 
6 
6 

1 

1 

i 

2 
4 

2 

1 
1 

1 

2 

1 
2 

7 
3 

13 
5 
6 
9 
3 

11 
5 
4 
8 
3 
1 
9 
4 
5 
1 

1 
1 
4 
2 
2 
6 

2 

5 
2 
3 

2 

1 

3 
4 

4 
7 
7 
1 
1 
4 
1 
2 
3 
7 
2 
2 
5 
3 
4 
3 
3 

i 

2 
4 

1 

2 

1 
1 
2 
1 

3 
1 
1 
3 
1 

i 

36 
42 
41 
19 
15 
35 
18 
27 
20 
26 
15 
14 
20 
26 
26 
26 
19 

11 

10 

13 

9 

6 

12 

10 

6 

11 

7 

6 

5 

11 

5 

10 

12 

4 

250 
160 

15 

16.  .  . 

84 

17 

18.  .  . 

19 

20 

21 

22.  . 

23 

61 

24.  .  . 

25 

26 . . .  . 

27 

28.  .  . 

29 

30 

146 

53 

363 
Table  III — Continued. 


October 

1.  .  . 

2.  .  . 
i'.'.'. 
4.  .  . 
5... 
6... 
7... 
8... 
9... 

10... 
11..  . 
12... 
13.  .. 
14... 
15... 
16... 
17.  .  . 
18... 
19... 
20... 

21.  .. 

22.  .. 
23... 
24.  .  . 
25... 
26... 
27... 
28... 
29... 
30... 
31.  .  . 


Manhattan.        Bronx 


Brooklyn.        Queens. 


Richmond. 


The   Citv. 


By  Days.       By  Weeks. 


16 

10 

12 

23 

13 

19 

12 

8 

13 

15 

11 

7 

3 

15 


364 


Table 
POLiOMY 

Cases  Reported 
Tune  1st  to 


Total  All  Ages. 

Under 

1  to2 

2  to  3 

3  to  4 

4  to  5 

Total 

5  to  6 

6  to  7 

lYear 

Years. 

Years. 

Years. 

Years. 

Under 

Years. 

Years. 

5  Years. 

Both 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

Sexes 

New  York  City — 

756 
3,863 
3,306 

416 
2,201 
1,905 

340 
i;662 
1,401 

50 
222 
209 

39 
200 
166 

104 
435 
361 

83 
334 
247 

105 
561 
400 

88 
365 
296 

57 
386 
300 

62 
271 
214 

41 
200 
201 

26 
153 
140 

357 
1,804 
1,471 

298 
1,323 
1,063 

22 
138 
132 

22 
109 
108 

11 
86 
80 

3 
71 
51 

July 

August 

September 

780 

435 

345 

45 

34 

89 

V6 

83 

66 

65 

56 

43 

26 

325 

258 

35 

14 

16 

14 

October 

193 

101 

92 

7 

10 

21 

18 

24 

15 

12 

18 

11 

9 

75 

70 

7 

6 

9 

4 

November.  ..... 

16 

3 

13 

1 

6 

3 

2 

1 

11 

December 

Total 

8,914 

5,061 

3,853 

533 

449 

1,011 

764 

1,173 

830 

820 

624 

496 

356 

4,033 

3,023 

334 

259 

202 

143 

Manhattan — 

76 

829 
1,191 

342 

41 
471 
672 
192 

35 
358 
519 
150 

3 
60 

88 
29 

1 

60 
71 
16 

10 
107 
131 

44 

13 

85 

107 

36 

14 
131 

142 
42 

7 

69 

118 

32 

V 

67 

103 

26 

9 

55 
66 

24 

4 
33 
62 
15 

3 

27 
45 
12 

38 
398 
526 
156 

33 
296 
407 
120 

1 
20 

48 
15 

1 

17 

28 

6 

i4 
26 

7 

9 

21 

5 

July    

September 

October 

89 

50 

39 

5 

4 

13 

11 

11 

3 

2 

9 

5 

2 

36 

29 

5 

1 

5 

2 

November 

9 

.    2 

7 

3 

2 

1 

6 

December 

Total 

2,536 

1,428 

1,108 

185 

152 

305 

255 

340 

229 

205 

165 

119 

90 

1,154 

891 

89 

53 

52 

37 

The  Bronx- 

10 
174 
332 

4 

85 

184 

6 

89 

148 

19 

2 

6 

21 

1 
12 

27 

19 

1 

25 
38 

1 
18 
29 

1 
17 
27 

1 
12 
21 

12 

28 

ii 

17 

3 

73 

139 

5 

67 

107 

'4 
11 

'4 
12 

1 

3 

10 

1 
5 
6 

July 

August 

September 

142 

81 

61 

5 

3 

13 

11 

12 

11 

13 

15 

14 

5 

57 

45 

4 

2 

4 

2 

October 

47 

17 

30 

6 

2 

4 

4 

8 

4 

4 

4 

3 

14 

25 

1 

3 

1 

1 

November 

3 

3 

2 

1 

3 

December 

Total 

708 

371 

337 

31 

38 

55 

57 

80 

67 

62 

53 

58 

37 

286 

252 

20 

21 

19 

15 

Brooklyn — 

626 
2,206 
1,208 

341 

1,276 

721 

285 
930 

487 

46 

124 

71 

35 

110 

56 

86 

254 
157 

66 

179 
85 

83 
325 
159 

V6 
203 
107 

47 
232 
115 

49 
158 
88 

31 
104 

78 

23 
90 
51 

293 

1,039 

580 

•  249 
740 
387 

18 
83 
36 

19 

72 
33 

10 
50 
28 

2 
38 
13 

July 

August 

September 

195 

105 

90 

8 

11 

21 

25 

20 

15 

16 

9 

7 

5 

72 

65 

10 

2 

4 

2 

October 

26 

13 

13 

1 

1 

1 

4 

2 

1 

3 

3 

7 

9 

1 

1 

1 

November 

4 

1 

3 

1 

1 

1 

1 

2 

December 

Total 

4,265 

2,457 

1,808 

250 

212 

520 

357 

591 

403 

411 

308 

220 

172 

1,992 

1,452 

148 

126 

93 

56 

Queens — 

10 

471 
521 

5 
265 
296 

5 
206 

225 

29 

?7 

17 
17 

1 
44 
43 

1 
38 
33 

2 

57 
50 

3 
53 
36 

•1 

51 

53 

1 
30 

3S 

1 
34 
?7 

21 

5 
215 
200 

5 
159 
146 

19 
33 

ii 

31 

ii 

16 

i4 

10 

July 

August 

September 

87 

49 

38 

3 

4 

10 

4 

8 

7 

8 

6 

7 

3 

36 

24 

6 

3 

5 

October 

31 

21 

10 

1 

5 

2 

5 

2 

5 

2 

2 

1 

18 

7 

2 

2 

November 

December 

Total 

1,120 

636 

484 

60 

38 

103 

78 

122 

101 

118 

74 

71 

50 

474 

341 

58 

47 

31 

29 

Richmond — 

34 
183 

25 
104 

9 

79 

1 
? 

6 

18 

2 
1? 

5 
23 

1 

?? 

1 
19 

2 
16 

5 
17 

4 

18 
79 

6 
61 

3 
12 

2 

5 

6 

',5 

July 

August 

54 

32 

22 

4 

3 

3 

11 

6 

7 

4 

6 

9 

26 

16 

4 

4 

1 

September 

14 

8 

6 

1 

1 

1 

2 

2 

1 

4 

4 

1 

1 

October. 

November 

December 

Total 

285 

169 

116 

7 

9 

28 

17 

40 

30 

24 

24 

28 

7 

127 

87 

19 

12 

7 

6 

365 


IV. 

ELITIS. 

By  Sex  and   Age. 

November  1st,  1916. 


7  to  8 
Years. 

8  to  9 
Years. 

9  to  10 
Years. 

Total 

Under 

10  Years. 

10tol4 

Years, 

Inc. 

15tol9 

Years, 

Inc. 

20to24 

Years, 

Inc. 

25  to  29 

Years, 

Inc. 

30  to  39 

Years, 

Inc. 

40  Years 
and 
Over. 

Total 

10  Years 

and 

Over. 

Colored. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

AI. 

F. 

M. 

F. 

M. 

F. 

10 
40 
49 
13 
3 

4 
47 
44 
16 

4 
37 
31 

9 

3 
29 
32 
10 

2 

1 
19 
2,2 

9 

1 

2 
18 
22 

7 

405 

2,124 

1,795 

407 

95 

1 

332 

1,597 

1,320 

319 

82 

11 

4 

40 

55 

16 

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1 

4 

34 

47 

12 

4 

1 

5 

13 

17 

3 

2 

1 

15 

12 

7 

1 

's 

11 

4 

1 
5 
6 
1 

2 

9 

11 

3 

i 

1 
4 
12 
3 
2 

"2 
5 
2 
1 

1 
2 
1 
2 

'5 
11 

"5 
3 

1 
3 

1 

11 

77 

110 

28 

6 

2 

8 
65 
81 
26 
10 

2 

115 

111 

81 

76 

62 

49 

4,827 

3,661 

119 

102 

40 

36 

23 

13 

26 

22 

10 

6 

16 

13 

234 

192 

61 

47 

1 

5 

11 

3 

1 

ii 

16 
6 

7 

10 

2 

6 
10 

1 
2 

6 
10 

5 

1 

'3 
3 
2 

40 
450 
631 
188 

48 

34 
342 
485 
140 

34 
6 

6 

12 

2 
2 
1 

1 
2 
18 
6 
1 

1 
3 
6 

'7 
4 

1 

'2 
1 
1 

"2 
9 
1 

i 

"2 
9 
1 

1 

"2 

'3 
8 

'3 
3 
1 
2 

1 

1 
21 
41 
4 
2 
2 

1 

16 

34 

10 

5 

1 

21 

3$ 

19 

19 

22 

8 

1,357 

1,041 

23 

28 

10 

12 

12 

4 

13 

13 

2 

11 

10 

71 

67 

31 

20 

'2 

7 
3 

'4 
2 

1 
6 

1 

3 
9 
2 

'2 
3 

i 

4 

2 

4 

83 

175 

72 

16 

6 

80 

142 

55 

29 

3 

i 

4 
5 

6 
2 
2 
1 

'3 
2 

'2 
3 
3 

i 

2 

'i 

1 

i 

i 
i 

'2 
9 
9 

1 

'9 
6 
6 

1 

12 

8 

27 

18 

5 

2 

6 

4 
29 
14 

4 

8 

2 
99 
"9 

4 

14 

3 

13 

8 

5 

5 

1 
10 

14 
1 

7 

2 

10 

8 

2 

350 

315 

10 

3 

25 

21 

4 

11 

3 
18 
16 
4 
1 
1 

5 

4 
9 

-4 
1 
2 

8 

-  1 
5 
2 
3 

3 

i 

6 

2 

1 
2 
3 

1 

2 

7 
1 
2 

1 

1 

"2 

1 
1 

2 

'2 

1 
2 

21 

22 

6 

28 

24 

10 

3 

1 

1 

6 

332 

1,231 

685 

96 

11 

1 

279 

902 

463 

80 

10 

2 

"i 

3 

2 

"2 
1 

9 

45 

36 

9 

■  2 

60 

'4 
13 

1 

51 

'4 

10 

3 

37 

'4 
6 
2 

29 

6 

5 
2 

26 

9 
6 

22 

'2 
7 
1 

2,356 

1,736 

53 

7 

17 

3 

1 

43 

's 

10 

i 

20 

'i 
3 

11 

'4 

7 

i 

6 

i 

12 

5 

6 

5 

3 

2 

101 

72 

18 

16 

5 

257 

274 

45 

20 

5 

196 

209 

38 

9 

i 
1 

"2 

22 

io 

16 

"i 

18 

1 

2 

17 
'3 

i 

12 

2 
3 

13 

i 

8 

i 

10 

'2 

601 

457 

28 

1 
1 
1 
2 

19 

4 
i 

4 

1 

1 

2 

2 

35 

27 

8 

5 

24 

103 

30 

6 

8 
77 
21 

6 

i 

1 

1 
1 
2 
2 

1 
2 

1 

_ 

4 

4 

5 

1 

1 

2 

163 

112 

5 

1 

' 

1 

6 

4 

3 

0 

366 

Table  V. 
Case   Fatality   of  Poliomyelitis. 

Of  Which  the 

0"sets.                                                                                           Following  Died  ^r-       it  ^  r* 
i^nding                                                                         Cases.       in  Same  or  Sub-^^'^  Fatality. 

^gek sequent  Weeks.  Per  cent. 

June     3 33                         1  3.0 

June    10 49                         4  8  0 

June    17.. 99                       16  16.0 

June    24 233                       54  23.1 

July      1 445                     119  26.7 

July      8 716                    190  26.5 

July    15 759                    214  28.2 

July    22 899                    255  28.3 

July    29 1,076                     289  26.8 

Aug.     5 1206                    374  31.0 

Aug.    12 935                    251  26.8 

Aug.    19 759                    207  27.2 

Aug.    26 505                     145  28.7 

Sept.     2 367                      98  26.7 

Sept.     9 238                       63  26.4 

Sept.   16 191                      51  26.7 

Sept.   23 139                      43  30.9 

Sept.   30 105                      27  25.7 

Oct.      7 86                      22  25.5 

Oct.     14 41                       11  26.8 

*  Tabulated  by  Division  of  Epidemiology. 

Table  VI. 

Poliomyelitis — Cases   and   Deaths. 

Rate  Per  1,000  Estimated  Population  at  Each  Age  Group,  June  1st  to  November  1st 

1916. 


Cases. 


Total.     Males. 


Fe- 
males.    Total. 


Case 
Deaths.  Fa- 

A ^  talitv 

Fe-      Botli 
Males,     males.  Sexes. 


Total   All   Ages    8,914  5,061  3,853 

Rate  per  1,000  Pop .  3.80  4.31  3.28 

Under  1  year....... 982  533  449 

Rate  per  1,000  Pop 18.40  19.70  17.06 

1  to  2  vears 1,775  1,011  764 

Rate  per  1,000  Pop 34.24  38.70  29.71 

2  to  3  years 2,003  1,173  830 

Rate  per  1,000  Pop 41.01  47.52  34.48 

3  to  4  vears 1,444  820  624 

Rate  per  1,000  Pop 29.85  33.50  26.10 

4  to  5  years 852  496  356 

Rate  per  1,000  Pop 18.04  20.77  14.65 

Total  under  5  years 7.056  4,033  3,023 

Rate  per  1,000  Pop 28.26  31.96  24.47 

5  to  6  vears 593  334  '259 

Rate  per  1,000  Pop 13.23  14.86  11.59 

6  to  7  years 345  202  143 

Rate  per  1,000  Pop 7.73  9.06  6.39 

7  to  8  years 226  115  111 

Rate  per  1  000  Pop 5.15  5.24  5.07 

8  to  9  years 157  81  76 

Rate  per  1,000  Pop 3.72  3.87  3.47 

9  to  10  vears HI  62  49 

Rate  per  1,000  Pop 2.70  2.99  2.40 

Total  Under  10  Years 8,488  4,827  3,661 

Rate  per  1,000  Pop 18.20  20.58  15.79 

Total  10  Yrs.  and  Over 426  234  192 

Rate  per  1.000  Pop 23  .25  .20 


2,406 
1.03 

423 
7.93 

521 
10.04 

435 
8.91 

311 
6.43 

207 
4.. -^8 

1,897 
7.60 


150 

3.35 

92 

2.06 

67 

1.53 

36 

.85 

32 

.78 

2.274 

4.88 

132 

.07 


1,408 
1.20 

240 

8.87 

312 

11.94 

255 

10.33 

185 

7.56 

136 

5.70 

1.128 
8.94 

89 
3.96 

45 
2.02 

38 
1.73 

18 
.86 

18 
.87 

1,336 

5.70 

73 

.08 


998 

.85 


183 
6.95 

209 
8.13 

180 
7.45 

126 

5.16 

71 

3.04 

769 
6.23 


61 
2.73 

47 
2.10 

29 
1.32 

18 
.84 

14 
.69 

938 

4.05 

59 

.06 


26.99 

43.08 
29.35 
21.72 
21.53 
24.30 

26.89 

25.30 
26.67 
29.65 
22.93 
28.83 

26.79 
30.99 


367 


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?-i^   en 

c 

rt  o: 

o3  o: 

c 

o3   o: 

368 


in  cq 

I — 1 

h- 1  ^ 

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JO  Aeq  Aq  smB3Q 

oo>0'>*i>o-*oooooi«ooio<na>oio[^-*-HO>ot^o\fOoorcON'*iorNim« 

NO 
00 

•^SSUQ  Aq  S3SB3 

QP^-^OOOOOst^OvOt^^PO-^OOOO^OvU^Cvl^^r^^iOOOOOr^OOt^ 
O\t^avOOCS^0N00f*^0N0\O-^CNr0O^^r0T^U0'O»O'^'^^t^iO<NO 

rtrtrtr-l                  «                  rt  rt  -H  -rt  Tl-H  -<»-(rt  rt  -H  «  —  rt  T-I.rt  rt  ,-1  CN 

00 

('Ot  oi  0  ai^DS 

Uasuns  o;  asu 

-ung) — ss9ujpno[3 

r0t^t^>OOCN(N-*OOC»iO>OO\t^O\Ot--c^)OQ.O00OO000000t^0000 

ON 

> 

•sjnoq  JO  jaquin^ 

— auiqsung 

^^CSt^OOOOO^ONf^Ot^OT-HONOsoO^^r^rOiC^CNNOiOOOOt^-^ 
lO  (N  ^O  0\        »/^  PO  »0  ^  O  t^  CS  00  l/^  00  lO  fC  Ov  CN  lO -^ '^  to  O  O  lO  O  O  ^  O  00 

13t 

1^ 
'm  00 

Oh 

•A^popyY 
33BJ9AV — puiM 

■rHrcrt<O<Nr000<NC0>OOr^tM— i-rtioOvOiO^O>00(NTt>r^O-HvorO>/5 

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Ttic^\OO00OtOO000\00t^0000l:^00O\0000Os00ONO\Os0\0s0MO^00t^ 

IS  On 

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■^•^r*^00f0CN0000'H0M^OO\CSt^O\O-^00-^V0lO>Of0P0V000(NOCNP0 

i^i'^t^sO^t^t^c^t^^t-^00r^t^O'Oi^t>-t~-t^t>-r^t^t^t^i^r^t-^r^t~-x 

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a; 

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ca 
Q 

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JO  Abq  Aq  sq^ESQ 

-H      -rtrt      .      .  rt      •      .      . -H      .  (N  rf  (N  (N  (N  C^  t^ -*  t^  Ov  O  CS  ■>*      . 

00 

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On -^  t^  lO  O  ^  00  t^  O  t^  ^  c^  CS  CN  ^  On  ^  ^  CS  T-l  CS  lO  fO  Ov -^ -^  ^  CN  IT)  Ov     ■ 
rt                                      rt       rt  w  rt  ,1  rt  ,-1  oj  (N  fO  ^  CN  r«:  ro  t»3  lO  O  lO  lO  vO  \0     • 

CM 

NO 

COT   0^  0  31BDS 

Uasuns  o;  ssu 
-ung) — ss3U!pnoi3 

"iCNOsTft^vOOOOOOl^-^t^OOON^OiOOiNrOl^OiOt^OiO-*     • 

a!  On 
OJ     . 

^NO 

lO 

OS 

•sinoq  JO  jaquinjvj 

— auiqsung 

Ost^  T)<  O  >/-)  00  O  OOOO  CO  OOOOrO  iNioro  OOO -H -nr^ro  OvOt^Tf  ts     • 
■*  r«5  ■*  uo —1  ^                 rt       oo  O  "       >-i  ■*  ro  CM  ro  cs  lO  CO  t^  O  O  t^  ro  r^  <-i     • 

|Xi 

z 

•A;poi3A 

33BJ9AV PUIM 

'HOOOOOO'^OOrOCSt^CNCOr^CSt^OOO'Mr^t^lOCSOOvt^CNOOt^iOt^ 

coo 

(3)      • 
euro 

On 

ol 

1—1 

Or^  lO  (N  (^  On  O  r^  O  00  u^  t^  ^  Ot^  O  O  CS  O  Os  ^  00  O  O '^  00  Ol>  fO  O      • 
rtvH,-l(Nrt          «  rt  r-.                          rt  rt  rt  rrj  (>J  rt  — 1  rt  tH  tN  -rt  rt  rt           Tl          «  T-l 

a 

H 

o 

(•jqSiupiui 
oi  ^qSiupii;^!) 
•uiE-ji  ie:iox 

oO'Hooooj-HootNOHoH-^'^HoooiNOOE-i'NOOooo   ■ 

qOn 

\o 

(•;uaD  jaj) 
•AipimnH  8ApE[a-a 

CS  ^-rt  t^rC^O  00  CSNO  !N  ONOOt^-*  00  lOiT)  <N  woo  OTt<-rt  n -*^  r^0>0     • 
-rji  lo  CO  Tt*  vC  O  On  On  On  00  On  t^  NO  00  0\  X  0\  NO  t^  NO  r^  lO  lO  C^  On  00  0^  r^  O  NO     * 

c 
oj>o 

CM 

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i^NOts  ^r-NOOoONO  NO  •*  ^  00-H  rf  OoOOO>nO  O  <N -*  OOnOOOn  ^  tNO     ■ 

NO  NO  NO  NO  NO  NO  NO  lO  "O  lO  »0  NO  NO  O  lO  NO  NO  t^  NO  NO  NO  NO  NO  NO  NO  t^  NO  t^  t^  t^       • 

C  rM 

lO 

00 

NO 

Q 

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rt  rt  tH -H  rt  rt—l  .rf  — 1 -rf  CS  CN  rNl  CM  CN  tN  (N  CS  (N  CN  ro      • 

•q:iE9a 
JO  Aeq  Aq  sq^Eaa 

•jasuQ  Aq  S9SE3 

»H       '^-Ht-H       •       -TjH       -^H       .       .fO^-l'-H       •tOf5CS^T-l»-<THi-l 

On 

(■OT  o?  0  'ai^as 

Uasuns  o;  asu 

-ung) — ssau!pnoi3 

^OOOOu-JOOTj-ONONOONt^wNOOOONOONt^rOw^oOOOoO-^NOf^c^ONO 

c 

aJNO 
(V     ■ 

^NO 

lO 

■o 

•sinoq  JO  jaqmnjvj 

— auiqsung 

ONOOc^O*HOONOroioONTiHr^OtNOrNjr^oONONOr^0^woO(MLDOONON 

'Son 

1^ 

ON 

<: 

OnOC^OuOCS       (N -^  "*  O -^  00  lO  Tt^  ^-i  ro  fXN -^ -^ '-h       Cn]  r^ -^  On  no  On  f<)  Tt* 

•A;popy\ 
aSBjaAy — -puiyy^ 

00<-llO0NO.OOlM0N00inCSIMN0c0rtOI^lO<MONCNOO0Nir)00O'*t^rt 

CO 

So 

On 

d 

NO^^0NO0N'*Oc0ONOOwu^(N00^o^^lO00(^^IO^OlO00O^^^)CSOlM00O 

w        w         ^  ^  ^  pr,  ^  (V5  rO  ^  ^        ^  Ol  (M  w  Csl  w  w  w        ^  w  w  *-(  r-H  *-i  CN 

K 
H 
Z 

o 

(•iqSiupiui 
o:)  ^q3iupiI/\[) 

•UIE>I   lE^OX 

oE-iooiNE-i'^oHoooooo-H(NOOooo-^f-iE-'OOrooHo 

-3 

00 

(•;uao  jaj) 
•A^ipimnH;  aApEp-g; 

0'-i.rHroiONOOOONOTjirt(MTt<mOOOONO^-*'*CNT)ft^rooOON^T)<r-(N 
r^iONONOt^>or^ioco»o-»*rO'^u^ONONi^-^io»0'*t^ONOOoo-^iooot^r^io 

c 

(UNO 

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lONONONOlONONONONOlONONOU^lOlOU^lOIDlOl^lOlOU^tONONONONOt^r^NO 

coo 

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T-irtWWWT-iTH.p-l»-lrt(NCSCS(SCNCS(NCSCNCSrOrO 

369 


JO  Abq  Aq  sqiBSQ 


.r^«'*0'^co^C'ioo»ri^'^»oO'-'Ocscsf^ro^O-^iOMic^c4f^cs 


yt'^^'^r^f';^':tr^'-H'^^Hr^-^f*^ 


.•     |- 


COT  01  0  3l^3S 

Uasuns  oi  asu 
-ung) — ss3uipnoi3 


Cf^XCCN't^CN»/:'-'-"X<MXOv'*r^,  Ot--r^^TtTtXOCOt^OX 


sjnoq  JO  jaquinNj 

— suiqsung 


•AjpopA 

3SBJ3AV pUJAV 


f<50r^r^'^0Xt^r 


;p^c>l'*f^Xr^'^r^XCN^C^.  r-r--Of^OsCc 


(•^qSiupim 
01  iqSiupiK) 
•UIT3-JJ  lElox 


ooocooooE-iooo  —  of-HdE-io-^oHcooHoooE-'f-'H 


(•:(uaD  jaj) 
■X:jipininH  sApBp-jj 


XCvOO-*'*'*"*X-*fO'OOXXCvClM  —  ■*OCM■*0'r!^~l^^XC^-^0 
■^ir-.iot^XXiOtoc^-^iOt^X-^v^Xi/^OwvCNu^vCsOii^-t^lOOu^Xw^O^ 


•draax  uEajx; 


^^  ,-t  »H  T^ -^  ^  ^ -TH -^^  1-!  (N  (N  CS  CS  CS  (N  CS  CN  (N  tN  c^  f^ 


■qiBaa 
JO  Abq  Aq  sqiBSQ 


•laSUQ  Aq  S3SB3 


(•OT  o:>  0  31^35 

;:(3suns  oi  asu 

-ung) — ss3uipn"oi3 


JT*©"^^'-^.  C'^Ou-,  --CC-^t^i^t^"".  "^t^XO 


•sjnoq  JO  jaqmnx 

— auiqsung 


I/-.  OCvC  —  t^'CCiOM^C>CS'C'^r~"-.  XX  —  CMXCv";  xr^-ccx-^-x 
CXr;^l-iu-!^C\Ol>)  —  OJCMl^irO  —  —  X  —  ts— 'O^COt^tNCSt^r^--     • 


r-r^r-qtniovOcor^f-XiMr^o  —  Cst-csCvXO  —  — '*0-'-  o)  lo  t--  C;  O 


■AlIOOTaA 


(•:iqSiuptui 
oi  iqSiupiH) 
•uiB-a  IB50X 


(•juao  ja<j) 
■AitpiuinH  aAUBp-g 


•dniax  uB3i/\r 


■qlBaa 
JO  Xbq  Aq  sqiBSQ 


•jasuQ  ^q  sasB3 


(•OT  01  0  '31«S 

l^asuns  or)  asu 

-ung) — ssauTptioio 

■sinoq  JO  jaqmriiSr 

— auiqsung 


•AjpopA 
aSBjaAV — puiAV 


CO  occo 


XiO-^OOCOCCOO'^OOOCCOHOCCXO 


K3SS•XO^§S^5;ot-t-XO^u^u~,t-./-.OXXt-^COlO^-X^^>/2 


jOOt^t^t^t^OOO^COr^r^^ 


CsO— tNrO'^>^^t^XO^O--^(NfO'«**' 


vO  t^  X  0»  O 


-f^<-;^>0>Ct~XO.O-Nr2^u-,^r;^^^-^^^--.^-jy- 


5??55::;?55^^^?:5^^^S5SSS?^S§2aJ?gSS^gs 


cs  "^  o  o  "^  c^  t^ 


COOCfOO  —  r'-Cf*CC;r<^  —  XC^C• 


vC  Ovt^  —  '-l 


Rx 


•^■*io00\0'*0io000vr0t 


•*OOX>OC^^•*<^00'-|■*0^00 


CiqStuptui 
01  iqSiuptIM) 

Ciuao  i3i) 
•AiipiranH  aAUBiaH 


=oooHhSS2hSooocH=oooooHHooooooc 


S'^vIO  Cd 


lo  t^  t^  X  c^  X  X 


rtiovOt^OOCvO-^ 


^<rs<^^^.  0»r-coc^C-^r^f22i2i:^2X)Scso^^es(NCS<N^N(N^r!c*^ 


370 


Table 

POLIOMYELITIS 

Tabulated  by 


June. 

July. 

August. 

CS 

Q 

3 

0 

!3 

3 
0 

0 

m 

c 
a; 

5 

•a 
s 
0 

5 

City. 

CO 

Q 

re 
re 
re 

0 

0 
0 

a 

0 
£ 

5 

City. 

C3 

Q 

1 

2 
3 
4 

5 

6 

7 

8 

9 

10 

11 

12 

13 
14 
15 
16 

17 
18 
19 

•  20 
21 
22 
23 
24 
25 
26 

27 
28 
29 
30 
31 

re 

re 
.c 

re 

12 
9 
11 
11 
12 

13 
14 
11 
10 

14 
11 

12 

11 
7 
10 
17 
11 
9 
16 

13 
13 
14 
12 
11 
10 
9 

11 
3 
4 
11 
10 

a 

c 
0 

« 

3 
'3 

'5 

'3 
3 

3 
3 
2 
2 

2 
6 

3 
1 
2 
1 

5 

4 

5 

4 
2 
2 

5 
3 
3 
2 

0 
0 

CQ 

21 
23 
25 
19 
26 

20 
19 
20 
17 
16 
15 
12 

11 

13 
11 
10 
10 
12 
9 

4 
15 
16 

6 
11 
15 

7 

7 
6 

5 
4 
8 

S 
0 

5 
10 

6 

5 
9 
9 

10 
13 
12 

5 
7 
4 
4 

6 

5 
5 
12 
4 
4 
2 

5 

10 

1 
1 

5 

1 

3 
7 
2 
2 
2 

3 
5 

'2 

2 
'2 

2 

City. 

1 
2 
3 

1 

7 

1 

(64)   8 

47 

38 

.  44 

41 

(309)  57 

44 
49 
46 
35 
43 
32 
(277)  30 

31 
31 

29 
41 
29 
26 
(219)  32 

2 
3 
4 
5 
6 
7 
8 

2 
"2 

\ 

1 
3 

'2 

20 
13 
14 
22 
12 
15 
16 

1 

i 
3 
2 

1 

2 

26 
14 
16 
24 
18 
18 
(136)  20 

4 
5 
6 
7 
8 
9 
10 

i 
i 

(3) 

9 
10 
11 
12 
13 
14 
15 

3 

4 
2 
3 

5 
4 

1 

2 
2 

1 
2 

18 
9 
18 
23 
18 
16 
8 

'3 
3 

5 
4 
3 

4 

3 

'2 
2 
2 

25 
18 
25 
33 
29 
26 
(171)  15 

11 
12 
13 
14 
15 
16 
17 

i 

(2)  .. 

16 

17 
18 
19 
20 
21 
22 

1 
3 
2 
9 
6 
8 
5 

1 

'2 

1 
1 
2 
2 

16 
16 
21 
15 
20 
20 
26 

3 
3 

4 
5 

6 
3 

5 

2 
2 
2 

"3 

4 

1 

23 
24 
31 
30 
36 
37 
(220)  39 

18 
19 
20 
21 
22 
23 
24 

2 
3 

2 
2 
2 

7 
7 

2 
4 
2 
2 
2 
7 
(26)   7 

27 
34 
40 
19 
29 
33 
(202)  20 

23 
24 
25 
26 
27 
28 
29 

12 
4 
8 
6 

14 
7 
7 

1 
4 
3 

i 

1 

16 
12 
15 
19 
21 
14 
20 

4 
6 

5 
4 
8 

4 
4 

'2 

2 

1 

33 
28 
33 
29 
44 
26 
(225)  32 

25 
26 
27 
28 
29 
30 

'3 

3 
1 
1 

4 
4 

6 
9 
11 
12 

1 

4 

7 

9 

10 

12 

14 

26 
19 

14 
20 

22 

30 
31 

9 
16 

24 
24 

10 
3 

43 
43 

9 

I  75 

2 

87 

149 

30 

528 

107 

32 

846 

342 

77 

413 

171 

19 

1,022 

(  )  Total  for  week. 


371 


IX. 

DEATHS. 
Date   of  Death— 1916. 


September. 

October. 

XOVE.MBER. 

Q 

c 

CS 
(3 

i 

E 
>. 
J:! 

C 

o 

u 

n 

c 
0 

2 

City. 

5 
2 

1 

>! 

u 

5 

g 

^ 

City. 

5 

5 

CS 

a 

n 
p 

s 

>. 

c 
(5 

0 

5 

•0 
2 

City. 

1 

2 

12 
6 

1 

4 

7 
11 

2 
2 

22 
(146)  23 

1 
2 
3 
4 
5 
6 
7 

1 
5 
5 
4 
.  1 
2 
5 

3 

1 
1 

'2 

2 
"3 

1 
'2 

i 

7 
7 
8 
4 
6 
4 
(44,   8 

1 
2 
3 

4 

5 

6 
7 
8 
9 
10 
11 

12 
13 
14 
15 
16 
17 
18 

19 
20 
21 
22 
23 
24 
25 

26 
27 
28 
29 
30 

2 
'2 

i 
i 

1 

i 

1 

i 

i 

4 

— ^ 

3 
4 
5 
6 
7 
8 
9 

7 

9 

10 

5 
7 
9 
7 

1 
3 
1 

2 
1 

1 

1 

10 
6 

2 
2 

4 

1 
2 
3 
2 
3 
1 
1 

11 
23 
25 
15 
14 
13 
(113)  12 

(5)   2 

8 
9 
10 
11 
12 
13 
14 

2 

'3 

1 
2 

'2 

1 

'2 
1 

i 

'2 
3 
2 

3 

1 

i 

i 
1 

4 
2 
8 
5 
3 
4 
(31)   5 

10 
11 
12 
13 
14 
15 
16 

2 
5 
10 
7 
3 
7 
5 

i 

2 

i 

1 

4 
5 

1 
2 
1 
5 
3 

'2 

1 
3 
2 

6 
11 
15 
10 

7 

15 

(73)   9 

(8)   2 

15 
16 
17 
18 
19 
20 
21 

3 

'2 

1 
] 

1 

2 

i 

1 

6 
1 

'2 

2 
3 

(17)   3 

17 
18 
19 
20 
21 
22 
23 

3 
3 
3 

1 
4 
1 
4 

1 

3 
2 
1 
2 

i 

1 
4 
3 
4 
1 
4 
2 

i 

1 
2 

3 
1 

5 
11 
9 
8 
7 
8 
(56)   8 

(2)  .. 

22 
23 
24 
25 
26 
27 
28 

1 

'2 

1 
2 

1 

'2 

1 

'2 

1 

i 

5 
2 

(15)   1 

24 
25 
26 
27 
28 
29 
30 

5 
4 
5 
3 
1 
4 
6 

i 
1 
1 

2 
2 

1 

2 

2 
3 
1 
2 
1 

1 
2 
1 
3 

1 

8 

7 

9 

11 

5 
9 

(57)   8 

(2)   1 

29 
30 
31 

i 

i 

1 
2 

1 

2 
3 
2 

158 

37 

104 

41 

4 

344 

49 

23 

28 

13 

1 

114 

11 

2 

2 

19 

372 


X 


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374 


Table 

Poliomyelitis  Deaths 

Death    Rate    Per    1.000    Estimated 

June   1st  to 


City  of  New  York. 


Total. 


Females. 


Manhattan. 


Total. 


Males. 


Females 


Total,  All  Ages.. 
Death  Rate. 


2.406 
1.03 


1,408 
1.20 


705 
.64 


402 
.73 


303 
.55 


Under  1  year.  .  . 
Death  rate. 


1  to  2  years .... 
Death  rate. 


2  to  3  years. . . . 
Death  rate. 


3  to  4  years. . .  . 
Death  rate. 


4  to  5  years . . 
Death  rate. 


Total  under  5  years. 
Death  rate.  .  .  . 


423 
7.93 


521 
10.04 


435 
8.91 


311 
6.43 


207 

4.38 


240 

8.87 


312 
11.94 


255 
10.33 


185 
7.56 


136 
5.70 


183 
6.95 


209 
8.13 


180 

7.45 


126 
5.  16 


71 
3.04 


154 
6.31 


155 
6.52 


127 
5.56 


73 
3.14 


47 
2.04 


1,897 
7.60 


1,128 
8.94 


769 
6.23 


556 
4.74 


80 
6.46 


44 
3.74 


33 
2.85 


318 
5.38 


74 
6.15 


66 

5.55 


55 
4.85 


29 
2.52 


14 
1.22 


238 
4.09 


5  to  6  years. . . . 
Death  rate. 


6  to  7  years .... 
Death  rate. 


7  to  8  years .... 
Death  rate. 


8  to  9  years. . . . 
Death  rate . 


9  to  10  years. .  . 
Death  rate . 


Total  under  10  years. 
Death  rate 


150 

3.35 


92 
2.06 


67 
1.53 


36 

.85 

32 


89 
3.96 


45 
2.02 


38 
1.73 


18 
.86 


18 
.87 


61 

2.73 


47 
2.10 


29 
1.32 


14 
.69 


40 
2.08 


25 
1.32 


16 
.85 


2,274 
4.88 


1,336 
5.70 


938 
4.05 


28 
2.91 


11 
1.17 


11 
1.18 


6 

.68 


379 
3.60 


12 
1.24 


14 
1.47 


3 
.34 


279 
2.67 


10  to  14 
15  to  19 
20  to  24 
25  to  29 
30  to  34 
35  to  39 
40  to  44 
45  years 


Total,  10  years  and  over. 
Death  rate 


years, 
years, 
years, 
years, 
years, 
years. 


nclusive. 
nclusive. 
nclusive. 
nclusive. 
nclusive. 
nclusive. 


years,  inclusive, 
and  over 


62 

27 

12 

14 

9 

5 

3 


32 
14 

8 

10 

3 

4 
2 


30 
13 
4 
4 
6 
1 
1 


132 
.07 


73 
.08 


59 
.06 


47 
.05 


23 
.05 


24 
.05 


375 


XL 


by  Age  and  Sex. 

Population   at   Each   Age    Group. 

November  1st,  1916. 


The  Bronx. 

Brooklyn. 

Queens. 

Richmond. 

Total. 

Males. 

Females. 

Total. 

Males. 

Females. 

Total. 

Males. 

Females. 

Total. 

Males. 

Females. 

167 
.69 

96 
.79 

71 
.59 

1,147 
1.42 

676 
1.69 

471 
1.16 

330 
2.15 

195 
2.50 

135 
1.79 

57 
1.39 

39 
1.83 

18 
.91 

28 
4.54 

14 
4.43 

14 
4.65 

189 
10.25 

111 
11.90 

78 
8.38 

45 
12.98 

29 
16.41 

16 
9.33 

7 
8.00 

6 
14.08 

1 
2.23 

29 
4.86 

14 
4.59 

15 
5.14 

267 
14.91 

166 
18.29 

101 
11.44 

62 
18.75 

36 
21.60 

26 
15.87 

8 
9.14 

7 
15.57 

1 
2.35 

26 
4.73 

14 
4.99 

12 

4.45 

217 
12.95 

126 
14.87 

89 
10.74 

50 
17.19 

35 
23.53 

15 
10.56 

15 
18.34 

6 
14.67 

9 
21.99 

23 

4.55 

16 
6.19 

7 
2.84 

155 
9.46 

90 
10.89 

65 
8.01 

55 
19.09 

30 
20.40 

25 
17.73 

5 
6.21 

5 
12.55 

14 
3.11 

11 

4.85 

3 
1.34 

101 
6.21 

60 

7.25 

41 
5.12 

39 
14.65 

27 
20.03 

12 
9.13 

6 
7.49 

5 
12.41 

1 

2.51 

120 
4.41 

69 
4.98 

51 

3.83 

929 
10.83 

555 
12.78 

374 
8.33 

251 
16.49 

157 
20.29 

94 
12.56 

41 
9.82 

29 
13.90 

12 
5.74 

10 
2.02 

4 
1.61 

6 

2.43 

73 
4.43 

41 
4.95 

32 
3.91 

22 
6.64 

13 

7.76 

9 

5.49 

5 
6.12 

3 
7.02 

2 
5.13 

8 
1.64 

6 
2.47 

2 
.82 

44 
2.63 

21 
2.50 

23 
2.77 

11 
3.34 

4 
2.45 

7 
4.21 

4 
4.70 

3 
6.95 

1 
2.39 

4 
.84 

2 
.83 

2 
.85 

27 
1.66 

16 
1.96 

11 
1.36 

17 
5.18 

7 
4.39 

10 
5.94 

3 
3.56 

2 
4.63 

1 

2.44 

8 
1.72 

5 
2.14 

3 
1.30 

12 

.77 

7 
.90 

5 
.63 

3 
.94 

3 
1.82 

4 
.88 

3 
1.31 

1 

.45 

15 
.99 

7 
.92 

8 
1.06 

5 
1.60 

3 
1.89 

2 
1.29 

154 
3.02 

89 

3.45 

65 

2.58 

1,100 
6.63 

647 

7.74 

453 
5.50 

309 
9.83 

184 
11.67 

125 
7.98 

53 
6.33 

37 
8.74 

16 
3.86 

5 
5 
1 
2 

3 
2 
1 
2 

2 
3 

^    ■  ■ 

26 
9 
4 
2 
2 
2 
2 

IS 
6 
2 
2 
2 
1 
1 

11 

3 
2 

i 

1 

18 
2 

1 

7 
2 

2 

2 

13 
.07 

8 
.08 

5 
.05 

47 
.07 

29 
.09 

18 
.06 

21 
.17 

11 
.18 

10 

.17 

4 
.12 

2 
.12 

2 
.13 

376 

Table  XII. 

POLIOMYELITIS. 

Cases  and  Deaths  in  Patients  Under  One  Year. 

(June  1 — November  1,  1916.) 


Age  in  Months. 

Cases. 

Deaths. 

Under  1  month 

7 

19 

27 

52 

70 

64 

98 

118 

104 

153 

149 

121 

3 

1  month 

13 

2  months 

10 

3  months 

17 

4  months 

24 

5  months 

34 

6  months 

45" 

7  months 

45 

8  months 

44 

9  months 

52 

10  months 

73 

1 1  months 

63 

Total 

982 

423 

Table  XIII. 

POLIOMYELITIS. 

Deaths  Under  10  Years,  According  to  Nativity  of  Mother. 

Death  Rate  Per  1,000  Estimated  Population  Nativity  of  Mothers  of  Children  Under 

10  Years. 

(June  1st  to  November  1st,  1916.) 


Deaths 

By  Nativity  of 

Mothers  of  Children 

Under  10  Years. 


Death  Rate 
per  1,000  Estimated 
Population.     Nativity 
of  Mothers  of  Child- 
ren Under  10 
Years. 


Austria-Hungary.  . 

Bohemia 

British  America .  .  . 

England 

France 

Germany 

Ireland 

Italy 

Russia  and  Poland 

Scotland 

Sweden 

Switzerland 

United  States 

Other  foreign 

Unknown 

Total 


2,274 


2.02 


yn 


Table  XIV. 

POLIOMYELITIS  DEATHS. 

Tabulated  by  Place  of  Death. 

(June  1st  to  November  1st,  1916.) 


Man- 
hattan. 

The 
Bronx. 

Brook- 
lyn. 

Queens. 

Rich- 
mond. 

New  York 
City. 

Tenements 

Institutions 

Dwellings 

194 

498 

8 

3 

2 

45 

107 

14 

"i 

524 
400 
221 

2 

77 

88 

163 

1 

1 

3 

28 

25 

1 

843 
1,121 

431 
5 
6 

Hotels 

Others 

Total 

705 

167 

1,147 

330 

117 

2,406 

Table  XV. 

POLIOMYELITIS. 

City  of  New  York,  1916. 

Onset  of  Cases  by  Days  for  Each  Borough  and  for  the  City. 


May. 

June. 

July. 

Day 

of 

Month 

d 

C 

3 
m 

V 

o 
o 

09 

c 

V 

5 

•V 

c 
o 

a 

2 

si 

U 

o 

c 

a 

c 

X 

s 
o 

u 

m 

H 

c 
_>. 

3 
o 

« 

c 
o 

V 

3 

a 

•d 
o 
E 

o 

s 

0 
0 

ea 

0 
M 
0 

H 

0 
0 

;-! 
P3 

5 

V 

5 

•D 
C 
0 

"a 
c 
H 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

i 
1 

2 

i 

i 

1 

4 

i 

3 

1 
1 
1 
3 
1 
1 
4 

i 
i 

i 

i 

i 

1 

4 

i 

4 

1 
1 
1 

3 

2 
2 
4 
2 
1 
2 
1 

2 
3 

3 

3 

1 
4 
3 
4 
3 
1 
4 
6 
7 
6 
7 
11 

i 

i 

1 
1 

3 
2 

2 

17 

1 

5 

4 

7 

8 

7 

6 

5 

8 

8 

14 

10 

9 

7 

17 

19 

20 

35 

39 

24 

28 

31 

33 

45 

50 

39 

46 

49 

55 

i 

2 
1 
2 

i 

2 
3 
0 

i 

1 

'i 

1 

4 

2 

'3 

'2 
2 
6 
3 

'4 
3 

19 

2 

7 

7 

8 

8 

9 

8 

8 

9 

10 

15 

11 

12 

9 

22 

20 

24 

36 

45 

27 

38 

35 

39 

52 

64 

52 

56 

63 

71 

12 
8 
21 
18 
20 
14 
22 
22 
14 
18 
10 
15 
21 
19 
27 
16 
32 
25 
30 
30 
32 
41 
50 
43 
40 
54 
53 
54 
36 
27 
69 

'2 
3 
2 
4 
4 
5 
4 
6 
5 
6 
2 
6 
3 
5 
8 
2 
2 

11 

11 
8 

11 
8 
6 

10 
4 
7 
7 
9 

11 

12 

72 
58 
70 
72 
73 
87 
78 
55 
67 
77 
71 
57 
68 
65 
75 
82 
60 
SO 
60 
74 
77 
74 
85 
78 
90 
63 
57 
81 
81 
78 
110 

6 
2 
4 
11 
3 
11 
8 
15 
10 
13 
15 
10 
19 
17 
16 
19 
17 
10 
21 
12 
23 
22 
22 
18 
21 
29 
28 
28 
18 
27 
42 

8 

'2 
4 
5 
5 
9 
8 
7 

12 
4 
6 
6 

13 
8 

11 
8 
3 
7 
9 
9 
8 
2 

11 
3 
5 
6 
5 
7 
2 
4 

98 
70 
100 
107 
105 
121 
122 
104 
104 
125 
106 
90 
120 
117 
131 
136 
119 
120 
129 
136 
149 
156 
167 
156 
164 
155 
151 
175 
151 
145 
237 

Total . 

6 

24 

1 

1 

32 

79 

12 

646 

13 

36 

786 

893 

184 

2.275 

517 

197 

4,066 

378 


Table  XV — Continued. 


August. 

September. 

October. 

Day 

K 

C 

Q 

s 

c 

01 

n 

c 

•a 

3 

^ 

cd 

3 

e 

3 

>. 

of 

rt 

>. 

m 

o 

U 

rt 

^ 

^ 

to 

O 

u 

a 

2 

_>. 

to 

0 

u 

Month 

J3 

a 

V 
J3 

o 
o 

C 
<V 
V 
3 

S 

J3 

O 

a 

m 

J5 

S 
o 

2 

d 

V 

4) 
3 

a 

o 

■(3 
o 

a 

m 

<u 

3 
0 

2 

3 
<u 

3 

E 
0 

0 

H 

n 

a 

(5 

H 

H 

n 

a 

5 

H 

S 

H 

m 

a 

s 

H 

1 

70 

16 

119 

38 

4 

247 

36 

14 

18 

7 

2 

77 

5 

■  4 

2~ 

2 

"~13 

2 

48 

7 

93 

33 

3 

184 

19 

12 

13 

13 

3 

60 

6 

6 

3 

3 

18 

3 

55 

7 

61 

34 

2 

159 

18 

10 

8 

5 

41 

1 

4 

3 

6 

14 

4 

43 

17 

84 

36 

1 

181 

25 

3 

10 

4 

i 

43 

6 

3 

1 

9 

5 

37 

15 

76 

38 

166 

18 

2 

17 

7 

1 

45 

2 

4 

6 

6 

57 

16 

56' 

27 

1 

157 

15 

4 

5 

8 

32 

7 

1 

i 

9 

7 

54 

14 

54 

22 

3 

147 

8 

4 

9 

6 

28 

4 

2 

6 

8 

32 

18 

51 

25 

5 

131 

12 

5 

13 

4 

34 

1 

'3 

--^ 

4 

9 

49 

12 

49 

14 

2 

126 

12 

2 

12 

3 

30 

'3 

. 

4 

10 

53 

14 

59 

26 

1 

153 

10 

5 

6 

7 

28 

2 

1 

5 

11 

47 

13 

35 

24 

3 

122 

18 

2 

3 

3 

.  • 

26 

1 

.  3 

5 

12 

55 

10 

40 

26 

4 

135 

7 

7 

5 

3 

22 

2 

4 

13 

51 

13 

50 

19 

2 

135 

7 

8 

10 

2 

27 

2 

3 

14 

47 

11 

41 

19 

119 

12 

3 

8 

4 

27 

's 

5 

15 

42 

11 

29 

16 

100 

15 

3 

8 

4 

30 

2 

'2 

4 

16 

49 

10 

39 

17 

118 

10 

3 

5 

5 

23 

1 

1 

17 

42 

11 

27 

20 

100 

9 

4 

4 

3 

20 

2 

2 

18 

35 

11 

48 

16 

HI 

11 

6 

4 

8 

29 

1 

3 

19 

45 

13 

27 

24 

113 

7 

3 

5 

3 

18 

4 

i 

6 

20 

51 

8 

25 

10 

96 

6 

2 

6 

3 

17 

1 

1 

3 

21 

35 

12 

22 

9 

79 

4 

3 

2 

6 

15 

1 

1 

22 

33 

7 

22 

8 

70 

8 

6 

3 

3 

20 

2 

3 

23 

33 

4 

17 

10 

65 

8 

7 

4 

4 

23 

2 

2 

24 

29 

10 

20 

12 

71 

12 

1 

9 

4 

26 

1 

i 

3 

25 

44 

7 

19 

17 

87 

6 

5 

2 

1 

15 

1 

2 

4 

26 

36 

3 

19 

10 

68 

6 

3 

4 

1 

14 

1 

'2 

3 

27 

32 

12 

22 

2 

3 

71 

7 

4 

6 

1 

18 

1 

1 

28 

31 

11 

14 

11 

67 

5 

2 

3 

2 

'  2 

14 

i 

'2 

3 

29 

19 

7 

8 

5 

39 

2 

1 

1 

1 

5 

30 

18 

4 

10 

4 

36 

6 

3 

4 

"i 

14 

31 

21 

5 

10 

6 

42 

Total . 

1,293 

329 

1.246 

578 

49 

3,495 

339 

137 

207 

125 

13 

821 

63 

28 

26 

29 

145 

379 

i'HfflHuirir  0/  Cases  by  W 

Table  XVI. 
'OLIOMYELITIS,  1916. 

ek  of  Onset,  Showing  Age 

and  Sex  Distribution 

Wal... 

£lel 

F=»„... 

nSL. 

Bo,„  Shx„. 

gIE 

iH 

Endln.. 

Under 

1 

2 

3 

4 

5 

6 

7 

8 

Q 

10 

Over 

Under 

1 

2 

3 

5 

6 

7 

8 

!. 

■0 

Over 

Under 

. 

2 

3 

4 

s 

6 

7 

8 

■> 

10 

over 

G^vVn. 

May 

Mai 
Juno 

June 
July 
July 
July 
July 
July 

AuE 

Aug 
Sep 
Sep 
Sep 
Sep 

\ 

:: 

;:: 

:: 

':: 

:: 

I 

E 

;; 

:: 

: 

' 

I 

::: 

:: 

I 

» 

: 

» 

:: 

:: 

': 

] 

J 

3 

» 

E 

m 

(1) 
"}» 

S's 

(1) 
"95 

'29 

1 

'i 

m 

"1 
(2) 

'Is 

(i) 
(n 

'2s 
'34 

'4' 

'I9 
(1) 

1 

"7 

(2) 

? 

(2) 

2 

336 

(11 

122) 

Totals 

SS7 

T073I117S 

7«   1   «(. 

337   1   203 

171 

84 

m 

41 

1117 

S.106 

444 

771 

iir.4 

633 

s 

262 

ISO 

lis 

71 

4g 

36 

143 

3.S09 

1.014  I1.8S7 

2.062 

1.4S1 

E47 

607 

360 

241 

l.'7 

ll» 

'" 

_337_ 

2" 

».J« 

'" 

^ 


Table  XVII. 
POLIOMYELITIS,  1916. 


5l 

mtnary  of  Cases  by  Week 

of  Ousel 

Showing  Age  and  Sex  Dislrihtuion 

«w,- 

Ma.es. 

ToWl 

F.H.L.S. 

ISa 

B0,„   SB.X.3. 

iE 

Both 

"""'"'■ 

Uudet 

■ 

^ 

3 

■> 

5 

« 

' 

8 

» 

10 

Uvcr 

Undsr 

. 

2 

3 

4 

5 

6 

7 

8 

10 

Uv„ 

Under 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

"1"' 

G^"'.. 

May  13 
May  20 

•S  " 

jSly     1 
July    s 
Jaly   15 
July  2! 
July  29 

StTl.  ^2 
StBl.    9 
Sect.  16 
Sept.  23 

fla' " 

I 

:: 

:: 

:: 

:: 

s 

? 

\ 

^ 

J 

;:' 

': 

f: 

:: 

i 

:: 

;: 

:: 

J 

\ 

J 

^ 

1 

... 

! 

I 

"la 
(1) 

*58 

"43 

(1) 
(1) 

(» 

*46 
'46 

(3) 

(11 

m 
(11 

(» 

"9 

(1) 

'j 

■; 

<2i 

: 

::: 

» 

Toal... 

197 

309 

332 

"■ 

111 

82 

61 

25 

21 

19 

' 

63 

1.423 

us 

243 

250 

165 

88 

65 

39 

33 

18 

' 

13 

45 

1,114 

351 

561 

592 

374 

206 

151 

102 

60 

40 

26 

18 

_!!!_ 

81 

2,672 

54 

Table  XVIII. 
POLIOMYELITIS,  1916. 


i"i(Hi»iar3i  0 

/  Cases  by  Week  of  Onse 

,J/l 

v,m„ 

/)»< 

and 

Sex  Disin 

till/oil 

M,..s. 

rE-.L.5. 

B„„  S.XBS. 

oyer 

Age 

H 

Sex 

Ending. 

Under 

1 

2 

3 

4 

5 

6 

7 

8 

9 

,0 

%" 

Mai... 

Under 

1 

2 

3 

4 

5 

6 

7 

, 

9 

10 

Ov„ 

l:,l.. 

Unler 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

Gi.en. 

ujy '1 

|B°p"'.  ^\ 

S.PI.    9 
StSi:  30 

\ 

i 

: 

] 

••! 

-'. 

i 

i 

1 

■■; 

1 

li 

■i 

1 

'1 

"1 

i 

J 

i 

; 

1 

(1) 

Total,. 

34 

61 

_!1 

j^ 

JL 

_!1 

_!!_ 

13 

" 

' 

^ 

,6 

368 

30 

50 

62 

53 

J!_ 

" 

" 

' 

" 

' 

' 

J^ 

303 

64 

'" 

^ 

"° 

_!1 





20 

JL 

JL 

' 

27 

" 

690 

^ 

Tabie  XIX. 
POLIOMYELITIS, 


Summa 

rj  0/  Case 

I  6j  H'.-.-- 

0/  0«jc( 

5/10IWH5 

Ag, 

" 

\d  Sex  Distribution. 

Mai... 

F.M...S. 

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cE 

H 

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eIS. 

-UnST 

, 

, 

3 

J 

5 

5 

J 

, 

, 

■  0 

°'S' 

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, 

. 

, 

•; 

s 

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w 

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— 

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= 

= 

= 

= 

= 

= 

= 

^ 

~ 

= 

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= 

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^'^^* 



Table  XIX 

OLIOMYELITIS,   191 

BOROUGH    OF   BROOKLYN. 

?k  of  Onset,  Showing 

Week 

Females. 

Ending. 

Under 
1 

1 

2 

3 

S 

6 

7 

8 

May     6 

May  13 
May  20 
May  27 
June     3 
June  10 
June  17 

"l 
4 
2 
6 

2 
2 
5 
5 
15 

'    2 

1 

5 

9 

12 

'  '4 
'  '5 

i 

'  i 
1 

June  24 

12 

35 

23 

16 

4 

1 

2 

July      1 

24 

47 

50 

25 

9 

3 

3 

July     8 

21 

56 

71 

47 

17 

7 

7 

1 

July    15 

29 

55 

52 

44 

13 

8 

4 

4 

July   22 

27 

59 

85 

57 

14 

8 

5 

2 

July   29 

34 

67 

73 

45 

15 

10 

9 

5 

Aug.     5 

29 

84 

82 

58 

16 

7 

7 

4 

Aug.   12 

26 

35 

44 

33 

10 

4 

1 

Aug.  19 
Aug.  26 

16 

8 

33 
19 

21 
19 

26 
12 

7 
1 

3 

2 

6 
3 

'  '3 

Sept.    2 
Sept.    9 
Sept.  16 
Sept.  23 
Sept.  30 
Oct.      7 
Oct.    14 
Oct.    21 
Oct.    28 

4 
5 
1 
2 
2 

14 

5 
5 
1 
5 
3 
1 

11 
4 
6 

2 
3 

1 
1 

10 

4 

4 

1 

2 

1 

1 
1 
J 

4 
1 
1 
1 

'  '3 

"i 

"i 

2 

'  i 

1 
1 

'  i 

Totals. . 

253 

553 

578 

395     > 

114 

59 

49 

24 

Table  XX. 
POLIOMYELITIS,  1916. 

BOROUGH  OF  QUEENS. 

of  Cases  by  Week  of  Onset,  Showing  Age  and  Sex  Dislri 


Table  XXI. 

Poliomyelitis    1916. 

borough  of  richmond. 

Summary  of  Cases  by  Week  of  Onset  Shoztnug  Age  and  Sex  Distribtition. 


M...S. 

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* 

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» 

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Over 

Untie, 

' 

^ 

^ 

* 

= 

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over 

Given. 

Sept.    2 
Sept.    9 
Sept.  16 
Sept.  23 
Sept.  30 

I 

\ 

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I 

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as  a 

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+  I+++ 


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+     ■+ 


:+  :+ 


+  I+++  :  :  :  :+ 


+  N      :+ 


ttlJ+ ;;+:++  J  it ;; ;  +++  ;;+ 


+ 


:+  :    +::+;+ 


.++++  :  :+  :++   +:+:;:    +++     ;++ 


:+  :    -H  :  :-«  :+ 


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+-«+;:  :++ 


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'^+++"ttt+^i+t  +1"tt+-H    +++  +++++i+  ++-H  :+++    -Ht++++ 


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>  3  2  5  X  2  2  X  X  2  g 

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388 


Table 
Mortality    Statistics,    City    of    New    York,     1915    and    \9\6— Figures    Prepared    hy 

Records    and    on    Their 


Subject. 


City  of  New  York. 


Manhattan. 


1915. 


1916. 


961 


(1) — Number  of  births,  January  1st  to  Sep- 
tember 30th,  inclusive 107,100 

(2) — Number  of  deaths  under  one  year  of  age 

January  1st  to  September  30th.  incl.  .     11,006 
(3) — Estimated  population  under  two  years  of 

age,January  1st  to  September  30th,inc.  238,501 
(4) — Number  of  deaths  under  two  years  of  age, 

January  1st  to  September  30th.  incl. .  .     14.002 
(5) — Infant  mortality  rate  under  one  year  of 

age.  January  1st  to  September  30th,  inc.         102 
(6) — Mortality  rate  under  two  years  of  age. 

January  1st  to  September  30th,  incl. .  .        78 . 5 
(7) — Number  of  true  cases  of  Poliomyelitis 
under  one  year  of  age.  January  1st  to 

September  30th,  inclusive 9 

(8) — Number  of  deaths  from  Poliomyelitis 
under  one  year  of  age.  January  1st  to 

September  30th,  inclusive 4 

(9) — Infant   mortality   rate   of   Poliomyelitis. 

January  1st  to  September  30th,  incl. .  .  .04 

(10) — Number  of  true  cases  of  Poliomyelitis 
under  two  years  of  age.  January  1st  to 

September  30th,  inclusive 10 

(11) — Number  of  deaths  from  Poliomyelitis 
under  two  years  of  age.  January  1st  to 

September  30th.  inclusive 7 

(12) — Mortality  rate  of  Poliomyelitis  under 
two  years  of  age,  January  1st  to  Sep- 
tember 30th,  inclusive .04 

(13) — Number  of  true  cases  of  Poliomyelitis  at 
all   ages,   January   1st  to  September 

30th,  inclusive 56 

(14) — Number  of  deaths  from  Poliomyelitis  at 
all   ages,   January   1st   to   September 

30th,  inclusive 10 

(15) — Number  of  deaths  under  one  year  of  age, 
January  1st  to  September  30th,  incl. : 

Diarrhoeal  Diseases 2,626 

Respiratory  Diseases 2,447 

Congenital  Diseases 4,252 

Contagious  Diseases 451 

Other  Diseases 1,230 

(16) — Number  of  deaths  under  two  years  of  age, 
January  1st  to  September  30th,  incl.: 

Diarthoeal  Diseases 3,090 

Respiratory  Diseases 3,754 

Congenital  Diseases 4.281 

Contagious  Diseases 1,121 

Other  Diseases 1,756 

(17) — Infant  mortality  rate.  January  1st  to 
September  30th.  inclusive: 

Diarrhoeal  Diseases 24.5 

Respiratory  Diseases 22 . 9 

Congenital  Diseases 39 . 7 

Contagious  Diseases 4.2 

Other  Diseases 11.5 

(18) — Mortality  rate  of  babies  under  two  years 
of  age,  January  1st  to  September  30th, 
inclusive: 

Diarrhoeal  Diseases 17.3 

Respiratory  Diseases 21.1 

Congenital  Diseases 24.0 

Contagious  Diseases 6.3 

Other  Diseases 9.8 

(19) — Total  number  of  cases,  January  1st  to 
September  30th,  inclusive: 

Measles 36,526 

Scarlet  Fever 8,806 

Diphtheria 11,808 

Whooping  Cough 5,537 

(20) — Infant  mortality  (total  number  of  deaths 
under  one  year),  January  1st  to  Sep- 
tember 30th,  inclusive: 

Measles 148 

Scarlet  Fever 9 

Diphtheria 135 

Whooping  Cough 169 


103,259 

49,544 

45.987 

10.122 

5,534 

4.967 

244.381 

111,174 

113.270 

13.238 

7,115 

6.429 

98 

112 

108 

72.7 

85.6 

75.6 

326 


395 

2 

142 

3.8 

.02 

3.1 

1,725 

5 

531 

886 

2 

279 

4.8 

.002 

3.28 

8,700 

35 

2,404 

2,290 

3 

648 

1,965 
2,293 
3,933 
430 
1.500 

1,221 

1,250 

2.167 

251 

645 

1.067 

1.103 

1.819 

274 

701 

2,321 
3,486 
3,950 
958 
2.523 

1,434 

1,919 

2,179 

663 

920 

1.243 
1.651 
1.829 
621 
1.083 

18.9 
■22.2 
38.1 
4.2 
14.5 

24.6 
25.2 
43.7 
5.1 
13.0 

23.2 
24.0 
39.6 
5.9 
15.2 

12.7 
19.0 
21.6 
5.2 
13.8 

17.3 
23.1 
26.2 
8.0 
11.1 

14.6 
19.4 
21.5 
7.3 
12.7 

20,946 
4,953 

11,249 
7,157 

14.061 
4.147 
5,627 
3,140 

10,347 
1,710 
5,278 
4,242 

141 

4 

169 

114 

94 

4 
82 
81 

107 

3 

96 

68 

389 

XXIII. 

the     Bureau     of     Records     and     Bureau     of    Preventable     Diseases     from     Their 
Basis     of    Computation. 


Brooklyn. 

The  Bronx. 

Queens. 

Richmond. 

1915. 

1916. 

1915. 

1916. 

1915. 

1916. 

1915. 

1916. 

36,673 

36,332 

12,127 

12,086 

6,966 

6,988 

1,790 

1,866 

3,522 

3,379 

1,019 

901 

731 

691 

200 

184 

84,641 

86,780 

23,758 

24,762 

15,185 

15,752 

3,743 

3,817 

4.514 

4,569 

1,279 

1,114 

858 

896 

236 

230 

98 

93 

84 

75 

105 

99 

112 

99 

71.3 

70.2 

72.0 

60.0 

75.6 

75.8 

84.4 

80.1 

62  1         97 


1 

179 

0 

23 

1 

44 

0 

7 

.03 

4.9 

0 

1.9 

.14 

6.3 

0 

4.0 

2 

871 

2 

104 

1 

174 

0 

45 

2 

441 

2 

47 

1 

104 

0 

15 

.03 

6.7 

.01 

2.5 

.08 

8.8 

0 

5.2 

11 

4,271 

6 

632 

4 

1.113 

0 

280 

3  1,120  3  147  1  319 

975  603  188  144  185  111 

827  868  206  158  138  129 

1,232  1,269  454  440  309  321 

116  94  49  40  25  18 

372  545  122  121  74  112 

1,145  731  240  164  209  140 

1,311  1,365  303  230  181  188 

1,244  1,275  456  440  311  322 

277  218  100  69  51  41 

537  980  170  211  106  205 

26.6  16.6  15.5  11.9  26.6  15.9 

22.5  23.9  17.0  13.1  19.8  18.5 

33.6  34.9  37.4  36.4  44.4  45.9 
3.2  2.6  4.0  3.3  3.6  2.6 

10.1  15.0  10.1  10.0  10.6  16.0 


18.1  11.2  13.5  8.8  18.4  11.8 

20.7  21.0  17.1  12.4  15.9  l3.8 

19.7  19.6  25.7  23.7  27.4  27.0 

4.4  3.4  5.6  3.7  4.3  34.4 

8.5  15.1  9.6  11.4  9.3  17.2 

12,331  5,334  5,629  3,055  2,902  1.730 

2,439  1,926  1,228  662  722  4^6 

3,637  3,737  1,792  1,276  623  608 

1,471  1.613  417  772  295  22, 


31  24  12  7                        6  3 

3  0  0  12  0 

39  39  11  21                         1  9 

43  31  26  11                       16  4 


0 

280 

0 

56 

57 

40 

26 

35 

90 

84 

10 

4 

17 

21 

62 

43 

40 

52 

91 

84 

20 

9 

23 

42 

31. S 

21.4 

14.5 

18.8 

50.3 

45.0 

5.6 

2.1 

9.5 

11.3 

22.2 

15.0 

14.3 

18.2 

32.5 

29.3 

7.1 

3.1 

8.2 

14.7 

1,612 

480 

170 

199 

129 

238 

204 

303 

5 

0 

0 

0 

2 

4 

3 

0 

390. 


Table  XXIII^ 


City  of  New  York. 


Manhattan. 


Subject. 


1915. 


1916. 


1915. 


(21) — Mortality  rate  from  all  causes,  based  on 
estimated  population,  under  two  years 
of  age,  January  1st  to  September  30th, 

inclusive 14,002 

Measles. . . . 415 

Scarlet  Fevei- 50 

Diphtheria 275 

Whooping  Cough. 391 

(22) — Infant  mortaUty  rate,  June  1st  to  Sep- 
tember 30th,  inclusive 5,227 

(23) — MortaUty  rate  for  babies  under  two  years 
of  age,  June  1st  to  September  30th, 

inclusive 6,610 

(24) — Infant  mortality  rate,  June  1st  to  Sep- 
tember 30th,  inclusive: 

Diarrhoea!  Diseases 2,004 

Respiratory  Diseases 951- 

Congenital  Diseases. 1,574 

Contagious  Diseases. 199- 

Other  Diseases 499 

(25) — Mortality  rate  of  babies  under  two  years 
of  age,  June  1st  to  September  30th, 
inclusive: 

Diarrhoeal  Diseases 2,377- 

Respiratory  Diseases 1,290- 

Congenital  Diseases 1,667- 

Contagious  Diseases. 459 

Other  Diseases 817 


13,238—72.7 

353—1.92 

16—   .09 

261—1.42 

335—1.83 


7,115- 

274 

31 

146 

222 


-85.6 


6,430-75 . 5 

273—3.21 

11—   .13 

153—1.80 

184—2.17 


—111.3     4,665—105.4     2,528—115.7     2,267—104.1 


-82.8      6,280—76.9      3.357—90.4      2,946—77.9 


-42.7 
-20.2 
-33.5 
-  4.2 
-10.6 


-29.8 
-16.2 
-20.9 
-  5.7 
-10.3 


1,362—28.9 
705—14.9 

1,646—34.9 
147—  3.1 

1,116—23.6 


1,652—20.2 
1,174—14.4 
1,652—20.2 
322—  3.9 
1,483—18.2 


906—41.5 
360—16.5 
917—42.0 
113—  5.2 
232—10.6 


1,066—28.7 
618—16.6 
924—24.9 
288—  7.7 
461—12.4 


732—33.6 
325—14.9 
766—35 . 2 
91—  4.2 
354—16.2 


870—23.0 
531—14.0 
770—20.4 
205—  5.4 
573—15.1 


Continued. 


391 


1915. 


Brooklyn. 

1916. 


1915. 


The  Bronx. 
1916. 


Queens. 


Richmond. 
1916. 


4,569—70.3      1.279 


4.514 

84 

14 

63 

116 


1.682—104.4  1,574—116.2       473—90.2 


56—      .86 

32 

2—      .03 

1 

56—      .86 

38 

104—  1.60 

39 

,114—60.0 

858 

16—      .86 

12 

2—      .02 

4 

28—  1.51 

23 

34—  1.83 

12 

389—72.7 

377- 

897—106.2  236 

7  13 

1 

17  5 

12  2 


230—80.3 
1 


-126.3      341—110.8    117—148.9    94—120.5 


2,100—74.3    2,245—77.3       582—73.3       488—91.3       442—87.1        476—90.4    129—103.2   125—97.3 


743—46 . 1 

472—29.3 

282—17.5 

56—  3.5 


423—26.1 

292 — 18.0 

515—31.8 

33—  2.0 


129—  8.0       621—38.3 


148—28.2 
58—11.1 

199—37.9 
17 —  3.2 


51- 


9.7 


87—16.3 
42—  7.8 
193—36.1 
13—  2.4 
54—10.1 


152—50.9 
49—16.4 

136—45.6 
10—  3.4 
30—10.0 


86—27.9 

36—11.7 

135—43.8 

9—  2.9 

75—24 . 4 


55—70.0 

12—15.3 

40—50.9 

3—  3.8 

7—  8.9 


34—43.6 
10—12.8 
37—47.4 
1—  1.3 
12—15.4 


892—31.5 
513-18.1 
368—13.0 
103—  3.6 
224—  7.9 


529—18.2 
494—17.0 
516—17.8 
70—  2.4 
636—21.9 


188—23.7 
82—10.3 

199—25.1 
39—  4.9 
74—  9.3 


104—12.6 
68—  8.2 

193—23.3 
27—  3.3 
96—11.6 


172—33.9 
63—12.4 

136—26.8 
23—  4.5 
48—  9.5 


112—21.3 
64-  12.2 

136—25.8 
16—  3.0 

148—28.1 


59—47.2 
14—11.2 
40—32.0 
6—  4.8 
10—  8.0 


37—28  8 
17—13.2 
37—28.8 
4—  3.1 
30—23.4 


f^Ji-'36.P2 


MONOGRAPH     SERIES 


No.  1.  The  Registration  and  Sanitary  Supervision  of  Pulmonary  Tuberculosis 
in  New  York  City.  By  John  S.  Billings,  Jr.,  M.  D.,  Chief  of  the  Division 
of  Commxmicable  Diseases. 

No.  2.  The  Tuberculosis  Climes  and  Day  Camps  of  the  Department  of  Health. 
By  John  S.  Billings,  Jr.,  M.D.,  Chief  of  the  Division  of  Communicable 
Diseases. 

No.  3.  Typhoid  Fever  in  New  York  City,  Together  with  a  Discussion  of  the 
Methods  Foimd  Serviceable  in  Studying  its  Occurrence.  By  Charles 
F.  Bolduan,  M.D.,  Assistant  to  the  General  Medical  Officer. 

No.  4.  The  Division  of  Child  Hygiene  of  the  Department  of  Health  of  The 
City  of  New  York.  By  S.  Josephine  Baker,  M.D.,  Director  of  Child 
Hygiene.    (Second  edition,  August,  1913.) 

No.  S.  The  Milk  Supply  of  New  York  City  and  its  Control  by  the  Department 
of  Health.  By  Ernst  J.  Lederle,  Ph.D.,  Commissioner  of  Health, 
and  Russell  Raynor,  Chief  of  the  Division  of  Food  Inspection. 

A  Guide  to  Some  of  the  Hygienic  Features  of  New  York  City.  By 
Charles  F.  Bolduan,  M.D.,  Director  Bureau  of  Public  Health  Education. 

Comments  on  Some  Plans  of  Hospital  Construction.  By  Hermann 
M.  Biggs,  M.D.,  General  Medical  OflBcer. 

The  Subsequent  History  of  Patients  Discharged  from  Tuberculosis 
Sanatoria.  An  investigation  carried  on  by  the  Council  of  Jewish 
Women. 

The  Law  of  the  Sanitary  Code  of  the  Board  of  Health  of  the  City  of 
New  York.    By  George  P.  Foulk,  LL.M. 

Fourth  Annual  Report,  Women's  Auxiliary  to  the  New  York  Department 
of  Health  Tuberculosis  Clinics,  Year  Endmg  November  1,  1914. 
(Second  edition.) 

Health  District  No.  1  (Experimental  Health  District).  Its  Organiza- 
tion and  Work  Performed  in  First  Quarter  of  191S. 

A  Clinical  and  Sanitary  Study  of  the  Fur  and  Hatters'  Fur  Trade. 
By  Louis  I.  Harris,  Chief,  Division  of  Industrial  Hygiene. 

Over  a  Century  of  Health  Administration  in  New  York  City.  By 
Charles  F.  Bolduan,  M.D.,  Director,  Bureau  of  Public  Health  Edu- 
cation. 

Year  Book  of  the  Bureau  of  Preventable  Diseases.  By  John  S. 
Billings,  M.D.,  Deputy  Commissioner. 

An  Analysis  of  Mortality  Returns  of  the  Sanitary  Areas  of  the  Borough 
of  Manhattan  for  the  Year  1915.  By  William  H.  Guilfoy,  M.D., 
Registrar,  and  Shirley  W.  Wynee,  M.D.,  Chief  of  Division  of  Statis- 
tic^ Research. 

No.  16.  The  Epidemic  of  Poliomyelitis  in  New  York  City  in  1916.  Based  on 
official  reports. 


No. 

6. 

No. 

7. 

No. 

8. 

No. 

9. 

No. 

10. 

No. 

11. 

No. 

12. 

No. 

13. 

No. 

14. 

No. 

15. 

Date  Due 

Jbni^"AR 

MAR  15 

1942 

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Ke^M..r:«^C.<u^  Dept,  of  health, 
iuonograph  on  the  epidemic  of 


ui  1916. 


